| Certificate Number | 306 | | Date Issued |
| Child Given Name | |
Croaker | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 May 1886 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | John |
Croaker | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Ireland | 40 | Father's Age |
| Mother's Given Name | Mary | Cahey | Mother's Maiden Name |
| Mother's Surname | Croaker | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Ireland | Mother's Birth Place |
| Mother's Age | 32 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |