| Certificate Number | 201 | | Date Issued |
| Child Given Name | Daisy |
Thornton | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Nov 1885 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | Jas. |
Thornton | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Wisconson | 26 | Father's Age |
| Mother's Given Name | Eva | La Hommedieu | Mother's Maiden Name |
| Mother's Surname | Thornton | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jno. I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno. I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno. I. Hostetter | | |