| Certificate Number | 1022 | | Date Issued |
| Child Given Name | |
Keefer | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Sep 1884 |
Ontario Story Co IA | Place of Birth |
| Father's Given Name | Abraham |
Keefer | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 40 | Father's Age |
| Mother's Given Name | Keziah | Daniels | Mother's Maiden Name |
| Mother's Surname | Keefer | Ontario Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 33 | 6 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merredith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merredith | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Merredith | | |