| Certificate Number | 342 | | Date Issued |
| Child Given Name | Devella Blanche Myrtle |
Ingram | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Feb 1882 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Lorenzo |
Ingram | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | | 34 | Father's Age |
| Mother's Given Name | Martha | Roark | Mother's Maiden Name |
| Mother's Surname | Ingram | Sioux Co IA | Mother's Residence |
| Mother's Age | 30 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk M.D. | | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk M.D. | | Certificate Signer's Address |
| Returned by Name | E.H. Monk M.D. | | |