| Certificate Number | 291 | | Date Issued |
| Child Given Name | Mary Alice |
Kay | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Aug 1889 |
McCallsburg Story Co IA | Place of Birth |
| Father's Given Name | Ole |
Kay | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Norway | 22 | Father's Age |
| Mother's Given Name | Della N. | Earp | Mother's Maiden Name |
| Mother's Surname | | McCallsburg Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |