| Certificate Number | 270 | | Date Issued |
| Child Given Name | |
Hempstead | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Mar 1886 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Albert C. |
Hempstead | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 27 | Father's Age |
| Mother's Given Name | Louise Olive | Applegate | Mother's Maiden Name |
| Mother's Surname | Hempstead | | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 28 | 4 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |