| Certificate Number | 200 | | Date Issued |
| Child Given Name | Margaret |
Barr | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Sep 1885 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | Chas |
Barr | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ireland | 43 | Father's Age |
| Mother's Given Name | Ellen | Holland | Mother's Maiden Name |
| Mother's Surname | Barr | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ireland | Mother's Birth Place |
| Mother's Age | 40 | 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 | | |