| Certificate Number | 80 | | Date Issued |
| Child Given Name | Martha M. |
Cozzens | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Jan 1890 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | J.N. |
Cozzens | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 29 | Father's Age |
| Mother's Given Name | | Sparrow | Mother's Maiden Name |
| Mother's Surname | | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |