| Certificate Number | 208 | | Date Issued |
| Child Given Name | |
Pickett | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 02 Sep 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | J.H. |
Pickett | Father's Surname |
| Father's Occupation | Druggist | | Father's Nationality |
| Father's Birth Place | Quincy IL | 25 | Father's Age |
| Mother's Given Name | May L. | Ayer | Mother's Maiden Name |
| Mother's Surname | Pickett | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Waterloo IA | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |