| Certificate Number | 345 | | Date Issued |
| Child Given Name | Agatha Lovena |
Haverly | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Feb 1886 |
Boone St Ames Story Co IA | Place of Birth |
| Father's Given Name | Charles E. |
Haverly | Father's Surname |
| Father's Occupation | Miller | | Father's Nationality |
| Father's Birth Place | New York | 45 | Father's Age |
| Mother's Given Name | Sarah E. | Lanning | Mother's Maiden Name |
| Mother's Surname | Haverly | Boone St Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 41 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |