| Certificate Number | 64 | | Date Issued |
| Child Given Name | |
Cole | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Dec 1888 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | A.C. |
Cole | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Goshen Indiana | 38 | Father's Age |
| Mother's Given Name | Matilda | Hay | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Somerset Co PA | Mother's Birth Place |
| Mother's Age | 34 | 6 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell Ia | Medical Attendant's Address |