| Certificate Number | 117 | | Date Issued |
| Child Given Name | |
Thomas | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 07 Feb 1881 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank |
Thomas | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | A. Hill | Hill | Mother's Maiden Name |
| Mother's Surname | Thomas | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Henri Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Henri Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | Henri Munk | | |