| Certificate Number | 119 | | Date Issued |
| Child Given Name | Charles F. |
Ashford | Child Surname |
| Child Sex | Male |
A | Child Race |
| Date of Birth | 21 Jan 1881 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Oliver G. |
Ashford | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 35 | Father's Age |
| Mother's Given Name | Josephine L. | Lonis | Mother's Maiden Name |
| Mother's Surname | Ashford | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 34 | 5 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Boggess | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Boggess | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.W. Boggess | | |