| Certificate Number | 123 | | Date Issued |
| Child Given Name | |
Shaw | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Apr 1888 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Dan |
Shaw | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 29 | Father's Age |
| Mother's Given Name | Libbie | Danskin | Mother's Maiden Name |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 26 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |