| Certificate Number | 103 | | Date Issued |
| Child Given Name | Mary G. |
Hostetter | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Mar 1888 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | John I. |
Hostetter | Father's Surname |
| Father's Occupation | Colo IA | | Father's Nationality |
| Father's Birth Place | Illinois | 31 | Father's Age |
| Mother's Given Name | Lillie C. | Hall | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |