| Certificate Number | 555 | | Date Issued |
| Child Given Name | |
O'Connell | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Dec 1882 |
Huxley Story Co IA | Place of Birth |
| Father's Given Name | John |
O'Connell | Father's Surname |
| Father's Occupation | Rail Roader | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 30 | Father's Age |
| Mother's Given Name | Mary | Hill | Mother's Maiden Name |
| Mother's Surname | O'Connell | Huxley Story Co IA | Mother's Residence |
| Mother's Nationality | Irish | Ireland | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |