| Certificate Number | 118 | | Date Issued |
| Child Given Name | Ida M. |
Bartlett | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Apr 1888 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | A.T. |
Bartlett | Father's Surname |
| Father's Occupation | Hotel Keeper | | Father's Nationality |
| Father's Birth Place | Suton VT | 39 | Father's Age |
| Mother's Given Name | Sarah | Worrell | Mother's Maiden Name |
| Mother's Surname | Bartlett | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 19 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |