| Certificate Number | 55 | | Date Issued |
| Child Given Name | |
French | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Jan 1885 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Chas |
French | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 29 | Father's Age |
| Mother's Given Name | Matilda J. | Haines | Mother's Maiden Name |
| Mother's Surname | French | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 29 | 2 | Number of Child This Mother |
| Medical Attendant's Name | M.A., Mrs. Martin | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |