| Certificate Number | 23 | | Date Issued |
| Child Given Name | |
Burns | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Aug 1880 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Fullen |
Burns | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 25 | Father's Age |
| Mother's Given Name | Anna E. | Allen | Mother's Maiden Name |
| Mother's Surname | Burns | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Geo P. Johnston | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo P. Johnston | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Geo P. Johnston | | |