| Certificate Number | 125 | | Date Issued |
| Child Given Name | |
Ozmun | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Feb 1889 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | H.W. |
Ozmun | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 42 | Father's Age |
| Mother's Given Name | Elizabeth | Smith | Mother's Maiden Name |
| Mother's Surname | | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 35 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |