| Certificate Number | 176 | | Date Issued |
| Child Given Name | Cleona B. |
Tett | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Sep 1885 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank J. |
Tett | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | England | 31 | Father's Age |
| Mother's Given Name | Emma | Bausar | Mother's Maiden Name |
| Mother's Surname | Tett | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | England | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton M.D. | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton M.D. | Zearing | Certificate Signer's Address |
| Returned by Name | F.S. Newton M.D. | | |