| Certificate Number | 406 | | Date Issued |
| Child Given Name | |
Wolen | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 02 Jun 1882 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Joseph |
Wolen | Father's Surname |
| Father's Occupation | Black Smith | American | Father's Nationality |
| Father's Birth Place | Indiana | 28 | Father's Age |
| Mother's Given Name | Susie G. | Stuckler | Mother's Maiden Name |
| Mother's Surname | Wolen | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 27 | 5 | Number of Child This Mother |
| Medical Attendant's Name | R.C. Alexander | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | R.C. Alexander | Collins IA | Certificate Signer's Address |
| Returned by Name | R.C. Alexander | | |