| Certificate Number | 123 | | Date Issued |
| Child Given Name | Otto Eugene |
Walston | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Jan 1889 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | W.H. |
Walston | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 29 | Father's Age |
| Mother's Given Name | Tillie | Smith | Mother's Maiden Name |
| Mother's Surname | | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |