| Certificate Number | 127 | | Date Issued |
| Child Given Name | Mary Hazel |
Elmore | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Mar 1889 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | J.M. |
Ellmore | Father's Surname |
| Father's Occupation | Butter Maker | | Father's Nationality |
| Father's Birth Place | Indiana | 42 | Father's Age |
| Mother's Given Name | Eva J. | Copeland | Mother's Maiden Name |
| Mother's Surname | | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 38 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |