| Certificate Number | 493 | | Date Issued |
| Child Given Name | |
Richardson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Feb 1887 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank B. |
Richardson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 26 | Father's Age |
| Mother's Given Name | Sarah Jane | Gamble | Mother's Maiden Name |
| Mother's Surname | Richardson | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |