| Certificate Number | 220 | | Date Issued |
| Child Given Name | Mary |
Corban | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 23 Aug 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Robert |
Corban | Father's Surname |
| Father's Occupation | Gardner | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 37 | Father's Age |
| Mother's Given Name | Ruth E. | Wilson | Mother's Maiden Name |
| Mother's Surname | Corban | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | Irish | Ireland | Mother's Birth Place |
| Mother's Age | 34 | 7 | 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 | | |