| Certificate Number | 291 | | Date Issued |
| Child Given Name | |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Feb 1886 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Eugene |
Smith | Father's Surname |
| Father's Occupation | Gardner | | Father's Nationality |
| Father's Birth Place | Ohio | 33 | Father's Age |
| Mother's Given Name | Eva M. | Adams | Mother's Maiden Name |
| Mother's Surname | Smith | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Age | 26 | 5 | 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 | | |