| Certificate Number | 115 | | Date Issued |
| Child Given Name | Archie W. |
Cowles | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 27 Jan 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Asa D. |
Cowles | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 31 | Father's Age |
| Mother's Given Name | Jane T. | | Mother's Maiden Name |
| Mother's Surname | Cowles | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 30 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Frazee | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Frazee | Colo IA | Certificate Signer's Address |
| Returned by Name | Geo. Frazee | | |