| Certificate Number | 18 | | Date Issued |
| Child Given Name | |
Smay | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 06 Oct 1888 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Smay | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | | Father's Age |
| Mother's Given Name | | Apple | Mother's Maiden Name |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |