| Certificate Number | 21 | | Date Issued |
| Child Given Name | |
Day | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Aug 1880 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | William |
Day | Father's Surname |
| Father's Occupation | Farmer | England | Father's Nationality |
| Father's Birth Place | Linconshire Eng | | Father's Age |
| Mother's Given Name | Clara | Airhart | Mother's Maiden Name |
| Mother's Surname | Day | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | | Mother's Birth Place |
| Mother's Age | | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Bogges | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Bogges | | Certificate Signer's Address |
| Returned by Name | J.W. Bogges | | |