| Certificate Number | 187 | | Date Issued |
| Child Given Name | |
Paine | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Jul 1885 |
Elwell Story Co IA | Place of Birth |
| Father's Given Name | Smith |
Paine | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Ella J. | Richardson | Mother's Maiden Name |
| Mother's Surname | Paine | Elwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown M.D. | | |