| Certificate Number | 359 | | Date Issued |
| Child Given Name | |
Conn | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Apr 1882 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | S.J. |
Conn | Father's Surname |
| Father's Occupation | Farm Laborer | | Father's Nationality |
| Mother's Given Name | Charity | Smith | Mother's Maiden Name |
| Mother's Surname | Conn | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Age | | 2 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |