| Certificate Number | 655 | | Date Issued |
| Child Given Name | |
Brown | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 02 Jun 1883 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | James |
Brown | Father's Surname |
| Father's Occupation | Engineer | American | Father's Nationality |
| Father's Birth Place | Ohio | 46 | Father's Age |
| Mother's Given Name | Nancy A. | Harris | Mother's Maiden Name |
| Mother's Surname | Brown | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 41 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Frank C. Thompson | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Frank C. Thompson | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Frank C. Thompson | | |