| Certificate Number | 110 | | Date Issued |
| Child Given Name | |
Whistler | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 21 Jan 1881 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | John |
Whistler | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 31 | Father's Age |
| Mother's Given Name | S.M | Swartzer | Mother's Maiden Name |
| Mother's Surname | Whistler | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo P. Johnston | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo P. Johnston | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Geo P. Johnston | | |