| Certificate Number | 360 | | Date Issued |
| Child Given Name | |
Davis | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 02 Apr 1882 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | J.E. |
Davis | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Virginia | 30 | Father's Age |
| Mother's Given Name | Leena Maria | Shankelfolk | Mother's Maiden Name |
| Mother's Surname | Davis | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |