| Certificate Number | 614 | | Date Issued |
| Child Given Name | |
Thompson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 02 Apr 1883 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | George C. |
Thompson | Father's Surname |
| Father's Occupation | Operator | American | Father's Nationality |
| Father's Birth Place | Wisconson | 27 | Father's Age |
| Mother's Given Name | May F. | Neely | Mother's Maiden Name |
| Mother's Surname | Thompson | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wisconson | Mother's Birth Place |
| Mother's Age | 27 | 1 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper | | |