| Certificate Number | 742 | | Date Issued |
| Child Given Name | |
Corbin | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 06 Jul 1883 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Robert |
Corbin | Father's Surname |
| Father's Occupation | Shoemaker | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 40 | Father's Age |
| Mother's Given Name | Ruth | Wilson | Mother's Maiden Name |
| Mother's Surname | Corin | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | Irish | Ireland | Mother's Birth Place |
| Mother's Age | 34 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |