| Certificate Number | 20 | | Date Issued |
| Child Given Name | Beryl |
Thatcher | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Oct 1889 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | C.N. |
Thatcher | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Indiana | 20 | Father's Age |
| Mother's Given Name | Anna | McDowell | Mother's Maiden Name |
| Mother's Surname | | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 35 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |