| Certificate Number | 743 | | Date Issued |
| Child Given Name | Opul Zaline |
Weir | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Robert |
Weir | Father's Surname |
| Father's Occupation | Farmer | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 32 | Father's Age |
| Mother's Given Name | Emma Jane | Bishop | Mother's Maiden Name |
| Mother's Surname | Weir | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | 27 | 1 | 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 | | |