| Certificate Number | 422 | | Date Issued |
| Child Given Name | Ethel |
Colby | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 02 Aug 1882 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Harry Harrison |
Colby | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Vermont | 26 | Father's Age |
| Mother's Given Name | Eva Ann | Wyatt | Mother's Maiden Name |
| Mother's Surname | Colby | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter M.D. | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter M.D. | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter M.D. | | |