| Certificate Number | 219 | | Date Issued |
| Child Given Name | Imogene |
Stevens | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Mar 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | John L. |
Stevens | Father's Surname |
| Father's Occupation | Lawyer | | Father's Nationality |
| Father's Birth Place | Vermont | 35 | Father's Age |
| Mother's Given Name | Rowena Estella | Edson | Mother's Maiden Name |
| Mother's Surname | Stevens | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 33 | 5 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |