| Certificate Number | 125 | | Date Issued |
| Child Given Name | |
Markhem | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 30 Jan 1881 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | John Cook |
Markham | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New York | 34 | Father's Age |
| Mother's Given Name | Maria E. | Parsons | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Connecticut | Mother's Birth Place |
| Mother's Age | 33 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Rachel Markham | Gilbert Station IA | Medical Attendant's Address |
| Certificate Signer's Name | Rachel Markham | Gilbert Station IA | Certificate Signer's Address |
| Returned by Name | Rachel Markham | | |