| Certificate Number | 125 | | Date Issued |
| Child Given Name | |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 Apr 1890 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Tillman |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 34 | Father's Age |
| Mother's Given Name | Sarah | Mullen | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 37 | 4 | Number of Child This Mother |
| Medical Attendant's Name | A.F. Bonny | Colo IA | Medical Attendant's Address |