| Certificate Number | 468 | | Date Issued |
| Child Given Name | Mae Amelia |
Irvine | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Dec 1886 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Johnston |
Irvine | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 29 | Father's Age |
| Mother's Given Name | Tena | Menzel | Mother's Maiden Name |
| Mother's Surname | Irvine | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | German | Germany | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Henry McClain | McCallsburg IA | Medical Attendant's Address |
| Certificate Signer's Name | P. McLain | | Certificate Signer's Address |