| Certificate Number | 841 | | Date Issued |
| Child Given Name | |
May | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Jan 1884 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Richard |
May | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 38 | Father's Age |
| Mother's Given Name | Enic | Kelley | Mother's Maiden Name |
| Mother's Surname | Maynard | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 35 | 9 | Number of Child This Mother |
| Medical Attendant's Name | A.S. Aplin M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | A.S. Aplin M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | A.S. Aplin M.D. | | |