| Certificate Number | 495 | | Date Issued |
| Child Given Name | Leslie |
Coil | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Feb 1887 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | William J. |
Coil | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Indiana | 31 | Father's Age |
| Mother's Given Name | Mary C. | Blase | Mother's Maiden Name |
| Mother's Surname | Coil | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 30 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Frank Thompson | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Frank Thompson | | |