| Certificate Number | 121 | | Date Issued |
| Child Given Name | Lydia May |
Page | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Apr 1888 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | A.J. |
Page | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 26 | Father's Age |
| Mother's Given Name | Lizzie | Day | Mother's Maiden Name |
| Mother's Surname | | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |