| Certificate Number | 730 | | Date Issued |
| Child Given Name | May |
Densmore | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 31 Aug 1883 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Jesse |
Densmore | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 39 | Father's Age |
| Mother's Given Name | Florence Amelia | Bailey | Mother's Maiden Name |
| Mother's Surname | Densmore | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 30 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |