| Certificate Number | 418 | | Date Issued |
| Child Given Name | |
Appleman | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Jul 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Thos B. |
Appleman | Father's Surname |
| Father's Occupation | Carpenter | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 40 | Father's Age |
| Mother's Given Name | Henrieta D. | Tubbs | Mother's Maiden Name |
| Mother's Surname | Appleman | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 37 | 7 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrer M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrer M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrer M.D. | | |