| Certificate Number | 427 | | Date Issued |
| Child Given Name | Genevieve |
Gossard | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Nov 1886 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | M.W. |
Gossard | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Indiana | 30 | Father's Age |
| Mother's Given Name | Sarah N. | Campbell | Mother's Maiden Name |
| Mother's Surname | Gossard | | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 30 | 3 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | George Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | George Stitzell | | |