| Certificate Number | 132 | | Date Issued |
| Child Given Name | Robt. J. |
McCollom | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Sep 1884 |
New Albany 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 | 32 | Father's Age |
| Mother's Given Name | Ida H. | Kent | Mother's Maiden Name |
| Mother's Surname | | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ogle Co IL | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Phebe, Mrs. Roberts | Colo IA | Medical Attendant's Address |