| Certificate Number | 979 | | Date Issued |
| Child Given Name | Cecile Grace |
Gossard | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Jun 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | M.W. |
Gossard | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 27 | Father's Age |
| Mother's Given Name | Sadie | Campbell | Mother's Maiden Name |
| Mother's Surname | Gossard | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |