| Certificate Number | 116 | | Date Issued |
| Child Given Name | |
Kinsell | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 31 Jan 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | John Webster |
Kinsell | Father's Surname |
| Father's Occupation | Grocer & Post Master | American | Father's Nationality |
| Father's Birth Place | Colo Story Co IA | 35 | Father's Age |
| Mother's Given Name | Euphema Louisa | Hall | Mother's Maiden Name |
| Mother's Surname | Kinsell | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Colo Story Co IA | Mother's Birth Place |
| Mother's Age | 29 | 4 | Number of Child This Mother |
| Medical Attendant's Name | L.C., Mrs. Butt | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | L.C., Mrs. Butt | Nevada IA | Certificate Signer's Address |
| Returned by Name | L.C., Mrs. Butt | | |