| Certificate Number | 110 | | Date Issued |
| Child Given Name | Rosa Etta |
See | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 May 1885 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Johnathan |
See | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Virginia | 66 | Father's Age |
| Mother's Given Name | Mary Ellen | Danson | Mother's Maiden Name |
| Mother's Surname | See | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 39 | 10 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Frank Thompson | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Frank Thompson | | |