| Certificate Number | 424 | | Date Issued |
| Child Given Name | |
Jackson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Aug 1882 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | James Perry |
Jackson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 25 | Father's Age |
| Mother's Given Name | Nancy Alice | O'Brien | Mother's Maiden Name |
| Mother's Surname | Jackson | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Jane, Mrs. Bartlett M.D. | | Medical Attendant's Address |
| Certificate Signer's Name | Jane, Mrs. Bartlett M.D. | | Certificate Signer's Address |
| Returned by Name | Jane, Mrs. Bartlett M.D. | | |