| Certificate Number | 606 | | Date Issued |
| Child Given Name | |
Mead | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Mar 1883 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Henry |
Mead | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Surname | Mead | Collins Story Co IA | Mother's Residence |
| Mother's Age | | 8 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper | | |