| Certificate Number | 120 | | Date Issued |
| Child Given Name | |
Shaffer | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 22 Feb 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Solomon M. |
Shaffer | Father's Surname |
| Father's Occupation | Telegraph Operator | American | Father's Nationality |
| Father's Birth Place | Ohio | 27 | Father's Age |
| Mother's Given Name | Mary C. | Martin | Mother's Maiden Name |
| Mother's Surname | Shaffer | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 34 | 5 | 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 | | |