| Certificate Number | 150 | | Date Issued |
| Child Given Name | |
McCoy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Apr 1889 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | John R. |
McCoy | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | West Virginia | 36 | Father's Age |
| Mother's Given Name | Annie | O'Donnell | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | England | Mother's Birth Place |
| Mother's Age | 35 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |