| Certificate Number | 516 | | Date Issued |
| Child Given Name | Martin Roger |
McCoy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Nov 1882 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | James |
McCoy | Father's Surname |
| Father's Occupation | Blacksmith | American | Father's Nationality |
| Father's Birth Place | Virginia | 27 | Father's Age |
| Mother's Given Name | Sarah | O'Donnell | Mother's Maiden Name |
| Mother's Surname | McCoy | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | English | England | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |