| Certificate Number | 192 | | Date Issued |
| Child Given Name | Andrew |
Kolb | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 26 Jun 1888 |
Story County IA | Place of Birth |
| Father's Given Name | Andrew |
Kolb | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Germany | 40 | Father's Age |
| Mother's Given Name | Katie | Picht | Mother's Maiden Name |
| Mother's Surname | | Story Co IA | Mother's Residence |
| Mother's Nationality | | Germany | Mother's Birth Place |
| Mother's Age | 36 | 10 | Number of Child This Mother |
| Medical Attendant's Name | Abby M. Miller | Nevada IA | Medical Attendant's Address |