| Certificate Number | 134 | | Date Issued |
| Child Given Name | |
Hempstead | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Mar 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Albert C. |
Hempstead | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 30 | Father's Age |
| Mother's Given Name | Olive | Applegate | Mother's Maiden Name |
| Mother's Surname | | Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 31 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |