| Certificate Number | 767 | | Date Issued |
| Child Given Name | |
Tripp | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Sep 1883 |
Gilbert Story Co IA | Place of Birth |
| Father's Given Name | Henry N. |
Tripp | Father's Surname |
| Father's Occupation | Plumber | American | Father's Nationality |
| Father's Birth Place | New York | 44 | Father's Age |
| Mother's Given Name | Eliza E. | Ford | Mother's Maiden Name |
| Mother's Surname | Tripp | Gilbert Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 38 | 8 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Gilbert IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Gilbert IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |