| Certificate Number | 1055 | | Date Issued |
| Child Given Name | William |
Campbell | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 06 Aug 1884 |
| Place of Birth |
| Father's Given Name | Jas. |
Campbell | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 24 | Father's Age |
| Mother's Given Name | Sarah | Cousins | Mother's Maiden Name |
| Mother's Surname | Campbell | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 24 | 1 | 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 | | |