| Certificate Number | 76 | | Date Issued |
| Child Given Name | |
Hefly | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Dec 1889 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | W.H. |
Hefly | Father's Surname |
| Father's Occupation | Druggist | | Father's Nationality |
| Father's Birth Place | Iowa | 33 | Father's Age |
| Mother's Given Name | Anna E. | Sellers | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |