| Certificate Number | 741 | | Date Issued |
| Child Given Name | |
Allard | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | Danl. |
Allard | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New Hampshire | 34 | Father's Age |
| Mother's Given Name | S.J. | McQuillen | Mother's Maiden Name |
| Mother's Surname | Allard | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 31 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Jno I Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I Hostetter | | |