| Certificate Number | 221 | | Date Issued |
| Child Given Name | |
Veign | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Jul 1885 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | Lewis |
Veign | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 23 | Father's Age |
| Mother's Given Name | | Tolbertson | Mother's Maiden Name |
| Mother's Surname | Veign | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 15 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |