| Certificate Number | 183 | | Date Issued |
| Child Given Name | |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Oct 1885 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | I.M. |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 35 | Father's Age |
| Mother's Given Name | | Smith | Mother's Maiden Name |
| Mother's Surname | Smith | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 27 | 4 | 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 | | |