| Certificate Number | 505 | | Date Issued |
| Child Given Name | Emma |
Donalson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Illinois Grove Marshall Co IA | Place of Birth |
| Father's Given Name | Edward |
Donaldson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Michigan | 22 | Father's Age |
| Mother's Given Name | Ella | Hallock | Mother's Maiden Name |
| Mother's Surname | Donaldson | Liberty Twp Marshall Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 21 | 2 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks M.D. | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Brooks M.D. | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Brooks M.D. | | |