| Certificate Number | 176 | | Date Issued |
| Child Given Name | |
Jackson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Oct 1885 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | James P. |
Jackson | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Indiana | 29 | Father's Age |
| Mother's Given Name | Alice | O'Brien | Mother's Maiden Name |
| Mother's Surname | Jackson | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 28 | 4 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |