| Certificate Number | 460 | | Date Issued |
| Child Given Name | Susanna Mary |
Blank | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Sep 1882 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Melorie J. |
Blank | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 28 | Father's Age |
| Mother's Given Name | Emma J. | Strudhen | Mother's Maiden Name |
| Mother's Surname | Blank | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 24 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Mead & Fish | Sherman Twp | Medical Attendant's Address |
| Certificate Signer's Name | Mrs. Mead & Fish | Sherman Twp | Certificate Signer's Address |
| Returned by Name | M.J. Blank | | |