| Certificate Number | 248 | | Date Issued |
| Child Given Name | |
Thaw | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Mar 1886 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | David |
Shaw | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | | Father's Age |
| Mother's Given Name | Lydia | Danskin | Mother's Maiden Name |
| Mother's Surname | Shaw | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | | 3 | Number of Child This Mother |
| Medical Attendant's Name | Jno Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno Hostetter | | |