| Certificate Number | 281 | | Date Issued |
| Child Given Name | |
Coffult | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 16 Dec 1881 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | S. Taylor |
Coffult | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 33 | Father's Age |
| Mother's Given Name | Sarah J. | Lyoid | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 25 | 4 | 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 | G.A. Meridith | | |