| Certificate Number | 856 | | Date Issued |
| Child Given Name | |
Brown | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Jan 1884 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | Lucius E. |
Brown | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 25 | Father's Age |
| Mother's Given Name | Rosana | Craft | Mother's Maiden Name |
| Mother's Surname | Brown | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |