| Certificate Number | 157 | | Date Issued |
| Child Given Name | |
Talbott | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Jul 1885 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Thos |
Talbott | Father's Surname |
| Father's Occupation | Booker | | Father's Nationality |
| Father's Birth Place | Illinois | 32 | Father's Age |
| Mother's Given Name | Elizabeth | Hardisty | Mother's Maiden Name |
| Mother's Surname | Talbott | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 28 | 2 | 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 | | |