| Certificate Number | 902 | | Date Issued |
| Child Given Name | |
Cole | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Mar 1884 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | N.A. |
Cole | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 40 | Father's Age |
| Mother's Given Name | Henrieta M. | Wilson | Mother's Maiden Name |
| Mother's Surname | Cole | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 37 | 4 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |