| Certificate Number | 556 | | Date Issued |
| Child Given Name | |
Learned | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Apr 1887 |
| Place of Birth |
| Father's Given Name | Henry |
Learned | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 44 | Father's Age |
| Mother's Given Name | Mary | Owens | Mother's Maiden Name |
| Mother's Surname | Learned | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 28 | 1 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |