| Certificate Number | 1054 | | Date Issued |
| Child Given Name | Hazel S. |
Platts | 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 | Silas E. |
Platts | Father's Surname |
| Father's Occupation | B Agent | | Father's Nationality |
| Father's Birth Place | New Hampshire | 34 | Father's Age |
| Mother's Given Name | Amanda C. | Hulse | Mother's Maiden Name |
| Mother's Surname | Platts | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 33 | 5 | Number of Child This Mother |
| Medical Attendant's Name | John I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | John I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | John I. Hostetter | | |