| Certificate Number | 150 | | Date Issued |
| Child Given Name | |
Richardson | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 15 Mar 1881 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Robert |
Richardson | Father's Surname |
| Father's Occupation | Farming | American | Father's Nationality |
| Father's Birth Place | Vermont Co VT | 53 | Father's Age |
| Mother's Given Name | Mary E. | Armstrong | Mother's Maiden Name |
| Mother's Surname | Richardson | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Rock Island Rock Co IL | Mother's Birth Place |
| Mother's Age | 44 | 10 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | 'mail' | | |