| Certificate Number | 96 | | Date Issued |
| Child Given Name | |
Vernon | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Jan 1890 |
McCallsburg Story Co IA | Place of Birth |
| Father's Given Name | Geo. R. |
Vernon | Father's Surname |
| Father's Occupation | Station Agt | | Father's Nationality |
| Father's Birth Place | Iowa | 30 | Father's Age |
| Mother's Given Name | Sarah E. | Smith | Mother's Maiden Name |
| Mother's Surname | | McCallsburg Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 25 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |