| Certificate Number | 784 | | Date Issued |
| Child Given Name | Sarah |
Mills | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Oct 1883 |
Grant Twp Hardin Co IA | Place of Birth |
| Father's Given Name | John |
Mills | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Hardin Co IA | 23 | Father's Age |
| Mother's Given Name | Adelia J. | Ufford | Mother's Maiden Name |
| Mother's Surname | Mills | Grant Twp Hardin Co IA | Mother's Residence |
| Mother's Nationality | | Marshall IA | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Addams | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Bunks | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Bunks | | |