| Certificate Number | 158 | | Date Issued |
| Child Given Name | F.O. |
Roe | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Jun 1885 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | W.L. |
Roe | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 29 | Father's Age |
| Mother's Given Name | Lizzie | Chitty | Mother's Maiden Name |
| Mother's Surname | Roe | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 29 | 3 | 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 | | |