| Certificate Number | 953 | | Date Issued |
| Child Given Name | |
Shaw | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Mar 1884 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Danl |
Shaw | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 25 | Father's Age |
| Mother's Given Name | Lydia | Danskin | Mother's Maiden Name |
| Mother's Surname | Shaw | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |