| Certificate Number | 945 | | Date Issued |
| Child Given Name | |
Mathis | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | J.D. |
Mathis | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 27 | Father's Age |
| Mother's Given Name | Nancy E. | Miller | Mother's Maiden Name |
| Mother's Surname | Mathis | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |