| Certificate Number | 56 | | Date Issued |
| Child Given Name | |
Gardner | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Dec 1889 |
Walnut Grove | Place of Birth |
| Father's Given Name | A.M. |
Gardner | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Wisconson | 32 | Father's Age |
| Mother's Given Name | Grace E. | Everett | Mother's Maiden Name |
| Mother's Surname | | Walnut Grove | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |