| Certificate Number | 475 | | Date Issued |
| Child Given Name | Miss |
Thomas | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 Oct 1882 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Franklin P. |
Thomas | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 30 | Father's Age |
| Mother's Given Name | Annie D. | 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 | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. McLain | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F., Dr. Newton | Nevada IA | Certificate Signer's Address |
| Returned by Name | F., Dr. Newton | | |