| Certificate Number | 436 | | Date Issued |
| Child Given Name | |
Bishop | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Apr 1882 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Bishop | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | | Father's Age |
| Mother's Given Name | Jane C. | Mead | Mother's Maiden Name |
| Mother's Surname | Bishop | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | | 9 | Number of Child This Mother |
| Medical Attendant's Name | R.C. Alexander M.D. | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | R.C. Alexander M.D. | Collins IA | Certificate Signer's Address |
| Returned by Name | R.C. Alexander M.D. | | |