| Certificate Number | 405 | | Date Issued |
| Child Given Name | Florence |
Tway | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 30 Sep 1886 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Cornelius |
Tway | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 42 | Father's Age |
| Mother's Given Name | Sarah M. | Allen | Mother's Maiden Name |
| Mother's Surname | Tway | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 34 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |