| Certificate Number | 154 | | Date Issued |
| Child Given Name | Henry Thomas |
Stillman | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Apr 1881 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Ephraim O. |
Stillman | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New York | 33 | Father's Age |
| Mother's Given Name | Annetta | Hemstock | Mother's Maiden Name |
| Mother's Surname | Stillman | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Island of Man | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cam | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |