| Certificate Number | 69 | | Date Issued |
| Child Given Name | Charles |
Sarsfield | Child Surname |
| Child Sex | Male |
A | Child Race |
| Date of Birth | 03 Oct 1880 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Robert |
Sarsfield | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Iowa | 23 | Father's Age |
| Mother's Given Name | Susan | Donahue | Mother's Maiden Name |
| Mother's Surname | Sarsfield | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Story Co IA | Mother's Birth Place |
| Mother's Age | 19 | 1 | 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 | | |