| Certificate Number | 936 | | Date Issued |
| Child Given Name | |
Henry | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Feb 1884 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | James |
Henry | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 29 | Father's Age |
| Mother's Given Name | Margeret | Drake | Mother's Maiden Name |
| Mother's Surname | Henry | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |