| Certificate Number | 290 | | Date Issued |
| Child Given Name | |
Rand | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 02 Jan 1882 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | David H. |
Rand | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 34 | Father's Age |
| Mother's Given Name | Lottie | Butler | Mother's Maiden Name |
| Mother's Surname | Rand | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | S.W. Honas M.D. | Edenville IA | Medical Attendant's Address |
| Certificate Signer's Name | S.W. Honas M.D. | Edenville IA | Certificate Signer's Address |
| Returned by Name | S.W. Honas M.D. | | |