| Certificate Number | 1057 | | Date Issued |
| Child Given Name | J. Ollie |
Byers | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Jun 1884 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | James |
Byers | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 37 | Father's Age |
| Mother's Given Name | S.M. | Allen | Mother's Maiden Name |
| Mother's Surname | Byers | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 37 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |