| Certificate Number | 248 | | Date Issued |
| Child Given Name | Gladys |
Allen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Sep 1890 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | C.W. |
Allen | Father's Surname |
| Father's Occupation | Physician | | Father's Nationality |
| Father's Birth Place | Vermont | 35 | Father's Age |
| Mother's Given Name | Angie S. | Stewart | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Vermont | Mother's Birth Place |
| Mother's Age | 36 | 3 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |