| Certificate Number | 408 | | Date Issued |
| Child Given Name | |
Norris | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Oct 1886 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | N. |
Norris | Father's Surname |
| Father's Occupation | Grain Merchant | | Father's Nationality |
| Father's Birth Place | Illinois | 26 | Father's Age |
| Mother's Given Name | Annie | Eccles | Mother's Maiden Name |
| Mother's Surname | Norris | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |