| Certificate Number | 159 | | Date Issued |
| Child Given Name | Blanche |
Hefley | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Jun 1885 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | W.A. |
Hefley | Father's Surname |
| Father's Occupation | Druggist | | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Anna E. | Sellers | Mother's Maiden Name |
| Mother's Surname | Hefley | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |