| Certificate Number | 417 | | Date Issued |
| Child Given Name | |
Cory | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Dec 1886 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Luther |
Cory | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 34 | Father's Age |
| Mother's Given Name | Sarah | Kent | Mother's Maiden Name |
| Mother's Surname | Cory | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 30 | 5 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Monk | | |