| Certificate Number | 100 | | Date Issued |
| Child Given Name | Mabel Josephine |
Taylor | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Apr 1885 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | James W.L. |
Taylor | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 26 | Father's Age |
| Mother's Given Name | Samantha | Carr | Mother's Maiden Name |
| Mother's Surname | Taylor | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jno. I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno. I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno. I. Hostetter | | |