| Certificate Number | 114 | | Date Issued |
| Child Given Name | |
Woodhouse | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Mar 1890 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Harry |
Woodhouse | Father's Surname |
| Father's Occupation | Butcher | | Father's Nationality |
| Father's Birth Place | Wisconson | 21 | Father's Age |
| Mother's Given Name | Emma J. | Hoch | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell IA | Medical Attendant's Address |