| Certificate Number | 69 | | Date Issued |
| Child Given Name | Oak George |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Feb 1885 |
Ablany | Place of Birth |
| Father's Given Name | Tillman M. |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 28 | Father's Age |
| Mother's Given Name | Sarah M. | Mullen | Mother's Maiden Name |
| Mother's Surname | Smith | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Sarah Black | New Albany Twp IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |