| Certificate Number | 501 | | Date Issued |
| Child Given Name | |
Hempstead | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Nov 1882 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Albert N. |
Hempstead | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | Olie | Applegate | Mother's Maiden Name |
| Mother's Surname | Hempstead | Grant Twp Story Co IA | Mother's Residence |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk M.D. | | |