| Certificate Number | 675 | | Date Issued |
| Child Given Name | |
Kurtz | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Jun 1883 |
| Place of Birth |
| Father's Given Name | Andrew |
Kurtz | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 29 | Father's Age |
| Mother's Given Name | Clara | Ren | Mother's Maiden Name |
| Mother's Surname | Kurtz | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 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 | | |