| Certificate Number | 30 | | Date Issued |
| Child Given Name | Mattie Velona |
Quick | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Apr 1884 |
Boone St Ames Story Co IA | Place of Birth |
| Father's Given Name | Milton Weston |
Quick | Father's Surname |
| Father's Occupation | Ass't Freight Agent | American | Father's Nationality |
| Father's Birth Place | Gainsville NY | 35 | Father's Age |
| Mother's Given Name | Katherine | Stamp | Mother's Maiden Name |
| Mother's Surname | Quick | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | English | Lincolnshire England | Mother's Birth Place |
| Mother's Age | 34 | 4 | Number of Child This Mother |
| Medical Attendant's Name | H.E., Mrs. Sherwood | Algona Kassuth Co IA | Medical Attendant's Address |
| Certificate Signer's Name | H.E., Mrs. Sherwood | Algona Kassuth Co IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |