| Certificate Number | 351 | | Date Issued |
| Child Given Name | |
Good | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Sep 1889 |
| Place of Birth |
| Father's Given Name | George |
Good | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 37 | Father's Age |
| Mother's Given Name | Mary J. | Sackett | Mother's Maiden Name |
| Mother's Surname | | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 32 | 3 | Number of Child This Mother |
| Medical Attendant's Name | A.P. Edgar | Collins IA | Medical Attendant's Address |