| Certificate Number | 447 | | Date Issued |
| Child Given Name | Bertha May |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Jun 1882 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Abram |
Smith | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Nevada Story Co IA | | Father's Age |
| Mother's Given Name | Rose Marion | Gerhart | Mother's Maiden Name |
| Mother's Surname | Smith | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | | Mother's Birth Place |
| Mother's Age | | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk M.D. | | |