| Certificate Number | 77 | | Date Issued |
| Child Given Name | |
Hall | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Sep 1880 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Haskel |
Hall | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | | Father's Age |
| Mother's Surname | | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | | 1 | Number of Child This Mother |
| Medical Attendant's Name | Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | James Bradley | Ames IA | Certificate Signer's Address |
| Returned by Name | James Bradley | | |