| Certificate Number | 512 | | Date Issued |
| Child Given Name | |
Allen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Jan 1887 |
Story County IA | Place of Birth |
| Father's Given Name | George |
Allen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 26 | Father's Age |
| Mother's Given Name | Lizzie | Snell | Mother's Maiden Name |
| Mother's Surname | Allen | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | R. Tripp | Clyde IA | Medical Attendant's Address |
| Certificate Signer's Name | R. Tripp | Clyde IA | Certificate Signer's Address |
| Returned by Name | R. Tripp | | |