| Certificate Number | 181 | | Date Issued |
| Child Given Name | |
Collins | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Mar 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | R.H. |
Collins | Father's Surname |
| Father's Occupation | Grain Dealer | | Father's Nationality |
| Father's Birth Place | Indiana | 34 | Father's Age |
| Mother's Given Name | Josie H. | Fleming | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Delaware | Mother's Birth Place |
| Mother's Age | 35 | 6 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |