| Certificate Number | 500 | | Date Issued |
| Child Given Name | |
McCord | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Mar 1887 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Abe S. |
McCord | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 30 | Father's Age |
| Mother's Given Name | Sarah E. | Bowman | Mother's Maiden Name |
| Mother's Surname | McCord | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |