| Certificate Number | 200 | | Date Issued |
| Child Given Name | |
Gates | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Jul 1888 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | M.L. |
Gates | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 36 | Father's Age |
| Mother's Given Name | Della | Gilbert | Mother's Maiden Name |
| Mother's Surname | | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 31 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |