| Certificate Number | 435 | | Date Issued |
| Child Given Name | |
Thomas | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Sep 1886 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Abner H. |
Thomas | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 36 | Father's Age |
| Mother's Given Name | Mattie | Vinell | Mother's Maiden Name |
| Mother's Surname | Thomas | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Monk | | |