| Certificate Number | 168 | | Date Issued |
| Child Given Name | Esther Elizabeth |
McCollister | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 May 1881 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Eli |
McCollister | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 35 | Father's Age |
| Mother's Given Name | Luelza | Cripps | Mother's Maiden Name |
| Mother's Surname | McCollister | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 27 | 6 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |