| Certificate Number | 223 | | Date Issued |
| Child Given Name | |
Thomas | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Nov 1885 |
Colfax Twp Boone Co IA | Place of Birth |
| Father's Given Name | Wm. |
Thomas | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 47 | Father's Age |
| Mother's Given Name | Hannah R. | Kelley | Mother's Maiden Name |
| Mother's Surname | Thomas | Colfax Twp Boone Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 42 | 9 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |