| Certificate Number | 334 | | Date Issued |
| Child Given Name | Betsey |
Henryson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Story City Story Co IA | Place of Birth |
| Father's Given Name | T.T. |
Henryson | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Illinois | 24 | Father's Age |
| Mother's Given Name | Julia | Erickson | Mother's Maiden Name |
| Mother's Surname | Henryson | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |