| Certificate Number | 175 | | Date Issued |
| Child Given Name | Asa |
Barnard | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 18 May 18981 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | George |
Barnard | Father's Surname |
| Father's Occupation | Farmer | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 35 | Father's Age |
| Mother's Given Name | Mary | McArthur | Mother's Maiden Name |
| Mother's Surname | Barnard | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 34 | 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 | | |