| Certificate Number | 55 | | Date Issued |
| Child Given Name | |
Kersey | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Dec 1888 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Henry |
Kersey | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | England | 54 | Father's Age |
| Mother's Given Name | Ann | Kinney | Mother's Maiden Name |
| Mother's Surname | | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 38 | 9 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |