| Certificate Number | 36 | | Date Issued |
| Child Given Name | J.F. |
Linch | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 26 Aug 1880 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Thos |
Lynch | Father's Surname |
| Father's Occupation | Blacksmith | Irish | Father's Nationality |
| Mother's Given Name | R.A. | Dolannee | Mother's Maiden Name |
| Mother's Surname | Lynch | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | | Mother's Birth Place |
| Mother's Age | | 4 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Frazee | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Frazee | Colo IA | Certificate Signer's Address |
| Returned by Name | 'By mail' | | |