| Certificate Number | 192 | | Date Issued |
| Child Given Name | Almeda |
Mills | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Sep 1885 |
Hubbard 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 | 25 | Father's Age |
| Mother's Given Name | Adelia J. | Ufford | Mother's Maiden Name |
| Mother's Surname | Mills | Hubbard Hardin Co IA | Mother's Residence |
| Mother's Nationality | | Marshall Co IA | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Brooks | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Brooks | | |