| Certificate Number | 26 | | Date Issued |
| Child Given Name | |
Colten | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | James |
Colten | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 41 | Father's Age |
| Mother's Given Name | Sarah Jane | Watt | Mother's Maiden Name |
| Mother's Surname | Colter | New Kelley Story Co IA | Mother's Residence |
| Mother's Nationality | Scotish | Scotland | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Meridith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Meridith | Ames IA | Certificate Signer's Address |
| Returned by Name | 'By Mail' | | |