| Certificate Number | 372 | | Date Issued |
| Child Given Name | |
Davis | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 07 Apr 1882 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Samuel |
Davis | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 39 | Father's Age |
| Mother's Given Name | Sarah | Wright | Mother's Maiden Name |
| Mother's Surname | Davis | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 24 | 7 | Number of Child This Mother |
| Medical Attendant's Name | F. Newton | | Medical Attendant's Address |
| Certificate Signer's Name | F. Newton | | Certificate Signer's Address |
| Returned by Name | F. Newton | | |