| Certificate Number | 68 | | Date Issued |
| Child Given Name | |
Coil | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Feb 1885 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Wm. J. |
Coil | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 29 | Father's Age |
| Mother's Given Name | Marg C. | Blare | Mother's Maiden Name |
| Mother's Surname | Coil | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 28 | 5 | 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 | | |