| Certificate Number | 605 | | Date Issued |
| Child Given Name | |
Dennison | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Mar 1883 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | James |
Dennison | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | Maria | Hauk | Mother's Maiden Name |
| Mother's Surname | Dennison | Collins Story Co IA | Mother's Residence |
| Mother's Age | | 10 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper | | |