| Certificate Number | 413 | | Date Issued |
| Child Given Name | |
Hall | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Oct 1886 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Charles |
Hall | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Wabasa WI | 39 | Father's Age |
| Mother's Given Name | Elizabeth | Elza | Mother's Maiden Name |
| Mother's Surname | Hall | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Missouri | Mother's Birth Place |
| Mother's Age | 36 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. McClure | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Mrs. Butt | Nevada IA | Certificate Signer's Address |
| Returned by Name | Mrs. Butt | | |