| Certificate Number | 1 | | Date Issued |
| Child Given Name | Mattie May |
Templeton | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 31 May 1880 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Thomas C. |
Templeton | Father's Surname |
| Father's Occupation | Painter & C. | American | Father's Nationality |
| Father's Birth Place | Nevada Story Co IA | 24 | Father's Age |
| Mother's Given Name | Sarah J. | Tanner | Mother's Maiden Name |
| Mother's Surname | Templeton | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Nevada Story Co IA | Mother's Birth Place |
| Mother's Age | 24 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E. Henri Monk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E. Henri Monk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E. Henri Monk | | |