| Certificate Number | 165 | | Date Issued |
| Child Given Name | |
Thomas | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Feb 1890 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Abner |
Thomas | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 40 | Father's Age |
| Mother's Given Name | Mattie | Venal | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |