| Certificate Number | 66 | | Date Issued |
| Child Given Name | Glenville Durand |
Cook | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 16 Oct 1880 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Chas W. |
Cook | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Lake Co IL | 38 | Father's Age |
| Mother's Given Name | Adalaid M. | French | Mother's Maiden Name |
| Mother's Surname | Cook | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Story Co IA | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Jno Dougherty | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno Dougherty | Colo IA | Certificate Signer's Address |
| Returned by Name | 'Mail' | | |