| Certificate Number | 24 | | Date Issued |
| Child Given Name | |
Thomson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Nov 1884 |
| Place of Birth |
| Father's Given Name | L.D. |
Thompson | Father's Surname |
| Father's Occupation | Labour | | Father's Nationality |
| Father's Birth Place | Iowa Center Story Co IA | | Father's Age |
| Mother's Given Name | Sarah | Richerson | Mother's Maiden Name |
| Mother's Nationality | | Iowa Center Story Co IA | Mother's Birth Place |
| Mother's Age | | 4 | Number of Child This Mother |
| Medical Attendant's Name | B.O., Mrs. Highley | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | B.O., Mrs. Highley | Iowa Center IA | Certificate Signer's Address |