| Certificate Number | 29 | | Date Issued |
| Child Given Name | Mildred |
May | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Oct 1889 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Richard |
May | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | | 48 | Father's Age |
| Mother's Given Name | Emma | Kelley | Mother's Maiden Name |
| Mother's Surname | | Union Twp Story Co IA | Mother's Residence |
| Mother's Age | 44 | 10 | Number of Child This Mother |
| Medical Attendant's Name | A.S. Aplin | Cambridge IA | Medical Attendant's Address |