| Certificate Number | 181 | | Date Issued |
| Child Given Name | |
Coggshall | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 29 May 1881 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Eugene |
Cogshall | Father's Surname |
| Father's Occupation | Farmer | U.S. | Father's Nationality |
| Father's Birth Place | Illinois | 34 | Father's Age |
| Mother's Given Name | Mary A. | Body | Mother's Maiden Name |
| Mother's Surname | Coggshall | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | U.S. | Ohio | Mother's Birth Place |
| Mother's Age | 29 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |