| Certificate Number | 199 | | Date Issued |
| Child Given Name | Walter |
Shaffer | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Nov 1885 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | I. |
Shaffer | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Sarah | Waltz | Mother's Maiden Name |
| Mother's Surname | Shaffer | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 3 | 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 | | |