| Certificate Number | 1011 | | Date Issued |
| Child Given Name | Harriett Phlora |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Jul 1884 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Eugene |
Smith | Father's Surname |
| Father's Occupation | Fruit Raiser | American | Father's Nationality |
| Father's Birth Place | Ohio | 32 | Father's Age |
| Mother's Given Name | Eva M. | Adams | Mother's Maiden Name |
| Mother's Surname | Smith | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 4 | 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 | | |