| Certificate Number | 286 | | Date Issued |
| Child Given Name | Florence M. |
Gaugh | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 27 Dec 1881 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | William |
Gaugh | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Missouri | 44 | Father's Age |
| Mother's Given Name | Virgin | Hart | Mother's Maiden Name |
| Mother's Surname | Gaugh | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Missouri | Mother's Birth Place |
| Mother's Age | 38 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Crane | | Medical Attendant's Address |
| Certificate Signer's Name | Wm Gaugh | | Certificate Signer's Address |
| Returned by Name | Wm Gaugh | | |