| Certificate Number | 182 | | Date Issued |
| Child Given Name | |
Richardson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Oct 1885 |
| Place of Birth |
| Father's Given Name | Frank B. |
Richardson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 25 | Father's Age |
| Mother's Given Name | Sarah J. | Gamble | Mother's Maiden Name |
| Mother's Surname | Richardson | Elwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 25 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | B.F. Brown M.D. | | |