| Certificate Number | 499 | | Date Issued |
| Child Given Name | Edna |
Bartlett | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 31 Jan 1887 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | A.T. |
Bartlett | Father's Surname |
| Father's Occupation | Hotel Keeper | | Father's Nationality |
| Father's Birth Place | Vermont | 39 | Father's Age |
| Mother's Given Name | Sarah E. | Worrall | Mother's Maiden Name |
| Mother's Surname | Bartlett | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |