| Certificate Number | 91 | | Date Issued |
| Child Given Name | |
Reynolds | Child Surname |
| Child Sex | |
W | Child Race |
| Date of Birth | 18 Jan 1885 |
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 | 52 | Father's Age |
| Mother's Given Name | Susan | Crooser | Mother's Maiden Name |
| Mother's Surname | Reynolds | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | New Jersey | Mother's Birth Place |
| Mother's Age | 36 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Croosser | New Albany Twp IA | Medical Attendant's Address |
| Certificate Signer's Name | John I. Hostetter | | Certificate Signer's Address |
| Returned by Name | John I. Hostetter | | |