| Certificate Number | 122 | | Date Issued |
| Child Given Name | |
Bowden | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Jan 1881 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | John B. |
Bowden | Father's Surname |
| Father's Occupation | Farmer | United States | Father's Nationality |
| Father's Birth Place | Ohio | 31 | Father's Age |
| Mother's Given Name | A.B. | Stots | Mother's Maiden Name |
| Mother's Surname | Bowden | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | United States | Ohio | Mother's Birth Place |
| Mother's Age | 27 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J. Daugherty | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J. Daugherty | Colo IA | Certificate Signer's Address |
| Returned by Name | 'By Mail' | | |