| Certificate Number | 211 | | Date Issued |
| Child Given Name | |
Morden | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 01 Aug 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | William G. |
Morden | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Canada | 30 | Father's Age |
| Mother's Given Name | Hannah | Chevill | Mother's Maiden Name |
| Mother's Surname | Morden | Colo Story Co IA | Mother's Residence |
| Mother's Age | 26 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J. Daugherty | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J. Daughtery | Colo IA | Certificate Signer's Address |
| Returned by Name | J. Daugherty | | |