| Certificate Number | 504 | | Date Issued |
| Child Given Name | Charles E. |
Cozzins | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Feb 1887 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | James N. |
Cozzins | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 26 | Father's Age |
| Mother's Given Name | Hattie M. | Sparrow | Mother's Maiden Name |
| Mother's Surname | Cozzins | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |