| Certificate Number | 91 | | Date Issued |
| Child Given Name | Clara Elmira |
Evens | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Nov 1880 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Thomas |
Evens | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 36 | Father's Age |
| Mother's Given Name | Emma | Day | Mother's Maiden Name |
| Mother's Surname | Evens | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 29 | 3 | Number of Child This Mother |
| Medical Attendant's Name | A.P. Edgar | Clyde IA | Medical Attendant's Address |
| Certificate Signer's Name | A.P. Edgar | Clyde IA | Certificate Signer's Address |
| Returned by Name | 'Mail' | | |