| Certificate Number | 112 | | Date Issued |
| Child Given Name | |
Reynolds | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 24 Jan 1881 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Reynolds | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 49 | Father's Age |
| Mother's Given Name | Susan | Croaker | Mother's Maiden Name |
| Mother's Surname | Reynolds | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Irish | Ireland | Mother's Birth Place |
| Mother's Age | 36 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Frazee | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Frazee | Colo IA | Certificate Signer's Address |
| Returned by Name | Geo. Frazee | | |