| Certificate Number | 130 | | Date Issued |
| Child Given Name | Hattie M. |
McCollom | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Mar 1890 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank |
McCollom | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ireland | 38 | Father's Age |
| Mother's Given Name | Ida H. | Kent | Mother's Maiden Name |
| Mother's Surname | | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ogle Co IL | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Phebe, Mrs. Roberts | Colo IA | Medical Attendant's Address |