| Certificate Number | 732 | | Date Issued |
| Child Given Name | |
Tupper | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Aug 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | W.W. |
Tupper | Father's Surname |
| Father's Occupation | Butcher | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 42 | Father's Age |
| Mother's Given Name | M.E. | Fowler | Mother's Maiden Name |
| Mother's Surname | Tupper | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | 34 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |