| Certificate Number | 220 | | Date Issued |
| Child Given Name | |
Cairns | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Aug 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Robert |
Cairns | Father's Surname |
| Father's Occupation | Com. Trad. | | Father's Nationality |
| Father's Birth Place | Wisconson | 32 | Father's Age |
| Mother's Given Name | Fanny | | Mother's Maiden Name |
| Mother's Surname | Cairns | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 25 | 3 | 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 | | |