| Certificate Number | 305 | | Date Issued |
| Child Given Name | |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Mar 1886 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Manville F. |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 25 | Father's Age |
| Mother's Given Name | Emma A. | Clay | Mother's Maiden Name |
| Mother's Surname | Smith | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 18 | 1 | 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 | | |