| Certificate Number | 1006 | | Date Issued |
| Child Given Name | Bertha Odessa |
Pontius | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Aug 1884 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Sylvester |
Pontius | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 43 | Father's Age |
| Mother's Given Name | Mary Ann | Paulin | Mother's Maiden Name |
| Mother's Surname | Pontius | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 38 | 11 | Number of Child This Mother |
| Medical Attendant's Name | J.H. Rosenburg | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.H. Rosenburg | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.H. Rosenburg | | |