| Certificate Number | 305 | | Date Issued |
| Child Given Name | |
Davis | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Jun 1889 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | S.R. |
Davis | Father's Surname |
| Father's Birth Place | Green Co PA | 46 | Father's Age |
| Mother's Given Name | | Wright | Mother's Maiden Name |
| Mother's Surname | | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | DeKalb Co IL | Mother's Birth Place |
| Mother's Age | 36 | 11 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |