| Certificate Number | 181 | | Date Issued |
| Child Given Name | |
Pollock | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Oct 1885 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | William |
Pollock | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 24 | Father's Age |
| Mother's Given Name | Hellen | Hedden | Mother's Maiden Name |
| Mother's Surname | Pollock | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jno. I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno. I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno. I. Hostetter | | |