| Certificate Number | 250 | | Date Issued |
| Child Given Name | Quennie |
Belt | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Jan 1886 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Benj |
Belt | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Iowa | | Father's Age |
| Mother's Given Name | Lovina | Dailey | Mother's Maiden Name |
| Mother's Surname | Belt | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 29 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Jno Hostetter | Colo IA | Medical Attendant's Address |