| Certificate Number | 937 | | Date Issued |
| Child Given Name | Thomas Claude |
Shickle | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Jun 1884 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | William |
Shickell | Father's Surname |
| Father's Occupation | Tanner | English | Father's Nationality |
| Father's Birth Place | England | 35 | Father's Age |
| Mother's Given Name | Martha | Thomas | Mother's Maiden Name |
| Mother's Surname | Shickell | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |