| Certificate Number | 178 | | Date Issued |
| Child Given Name | John Thomas |
Jones | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Jul 1890 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Amos P. |
Jones | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Alice Elizabeth | McCartney | Mother's Maiden Name |
| Mother's Surname | Jones | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |