| Certificate Number | 1056 | | Date Issued |
| Child Given Name | J. |
Sorssafield | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Jun 1884 |
Collins | Place of Birth |
| Father's Given Name | Robt |
Sorssafield | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 28 | Father's Age |
| Mother's Given Name | Susan A. | Donnahoo | Mother's Maiden Name |
| Mother's Surname | Sorssafield | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 2 | 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 | | |