| Certificate Number | 111 | | Date Issued |
| Child Given Name | |
Cole | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 May 1885 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | A.P. |
Cole | Father's Surname |
| Father's Occupation | Merchant | American | Father's Nationality |
| Father's Birth Place | Indiana | 35 | Father's Age |
| Mother's Given Name | Matilda | Hay | Mother's Maiden Name |
| Mother's Surname | Cole | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 29 | 6 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell Ia | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Maxwell IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |