| Certificate Number | 772 | | Date Issued |
| Child Given Name | |
Tomilsen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Sep 1883 |
Peoria City Polk Co IA | Place of Birth |
| Father's Given Name | William |
Tomilsen | Father's Surname |
| Father's Occupation | Farmer | English | Father's Nationality |
| Father's Birth Place | England | 31 | Father's Age |
| Mother's Given Name | Mary | Hawkins | Mother's Maiden Name |
| Mother's Surname | Tomilsen | Peoria City Polk Co IA | Mother's Residence |
| Mother's Nationality | American | | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell IA | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Maxwell IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |