| Certificate Number | 111 | | Date Issued |
| Child Given Name | Bertha Mariah |
Williams | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 28 Jan 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | James M. |
Williams | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 30 | Father's Age |
| Mother's Given Name | Martha E. | Robinson | Mother's Maiden Name |
| Mother's Surname | Williams | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Maryland | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Geo Frazee | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Frazee | Colo IA | Certificate Signer's Address |
| Returned by Name | Geo Frazee | | |