| Certificate Number | 336 | | Date Issued |
| Child Given Name | |
Thom | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 16 Jan 1882 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | Daniel W. |
Thom | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 24 | Father's Age |
| Mother's Given Name | Elizabeth Ann | Carl | Mother's Maiden Name |
| Mother's Surname | Thom | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton M.D. | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton M.D. | Zearing | Certificate Signer's Address |
| Returned by Name | F.S. Newton M.D. | | |