| Certificate Number | 282 | | Date Issued |
| Child Given Name | |
Applegate | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank |
Applegate | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | Frank, Mrs. | | Mother's Maiden Name |
| Mother's Surname | Applegate | | Mother's Residence |
| Mother's Age | | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.N. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.N. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.N. Munk | | |