| Certificate Number | 45 | | Date Issued |
| Child Given Name | |
Cassem | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Nov 1888 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Thos. P. |
Cassem | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Illinois | 33 | Father's Age |
| Mother's Given Name | Carrie | Nelson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 6 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |