| Certificate Number | 212 | | Date Issued |
| Child Given Name | Carrie M. |
Henry | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Jun 1889 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Jas. T. |
Henry | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Indiana | 33 | Father's Age |
| Mother's Given Name | Alice E. | Pizer | Mother's Maiden Name |
| Mother's Surname | | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | | England | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |