| Certificate Number | 57 | | Date Issued |
| Child Given Name | |
Campbell | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Jan 1885 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Dave |
Campbell | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 22 | Father's Age |
| Mother's Given Name | Lillie Etta | Bowen | Mother's Maiden Name |
| Mother's Surname | Campbell | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa Center Story Co IA | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Frank Thompson | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Frank Thompson | | |