| Certificate Number | 985 | | Date Issued |
| Child Given Name | Cornelius Washington |
Gross | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Jul 1884 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | C.W. |
Gross | Father's Surname |
| Father's Occupation | Merchant | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 52 | Father's Age |
| Mother's Given Name | Mary E. | Bosley | Mother's Maiden Name |
| Mother's Surname | Gross | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 37 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.H. Rosenberger | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.H. Rosenberger | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.H. Rosenberger | | |