| Certificate Number | 212 | | Date Issued |
| Child Given Name | Robert Jr. |
Corbin | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Jul 1888 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Robert |
Corbin | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Ireland | 52 | Father's Age |
| Mother's Given Name | Ruth | Wilson | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Ireland | Mother's Birth Place |
| Mother's Age | 41 | 12 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |