| Certificate Number | 209 | | Date Issued |
| Child Given Name | |
Vest | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 29 Jul 1881 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Eldoren |
Vest | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 22 | Father's Age |
| Mother's Given Name | Jennie | Briley | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Meridith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Meridith | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Meridith | | |