| Certificate Number | 449 | | Date Issued |
| Child Given Name | Colista P. |
Bucker | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 30 Sep 1882 |
Columbia Wisconson | Place of Birth |
| Father's Given Name | Jammie Henry |
Bunker | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 27 | Father's Age |
| Mother's Given Name | Eliza J. | Wickham | Mother's Maiden Name |
| Mother's Surname | Bunker | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | ?. C. Jessey | | Medical Attendant's Address |
| Certificate Signer's Name | ?. C. Jessey | | Certificate Signer's Address |
| Returned by Name | ?. C. Jessey | | |