| Certificate Number | 847 | | Date Issued |
| Child Given Name | Carrie |
Ballard | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Nov 1883 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Elias |
Ballard | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 33 | Father's Age |
| Mother's Given Name | Mahala | Spencer | Mother's Maiden Name |
| Mother's Surname | Ballard | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 31 | 4 | Number of Child This Mother |
| Medical Attendant's Name | P., Mrs. Hopkins | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | P., Mrs. Hopkins | Cambridge IA | Certificate Signer's Address |
| Returned by Name | P., Mrs. Hopkins | | |