| Certificate Number | 240 | | Date Issued |
| Child Given Name | |
Culeman | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Sep 1890 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | Jas |
Culeman | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | | 33 | Father's Age |
| Mother's Given Name | Mosy | Brennan | Mother's Maiden Name |
| Mother's Surname | | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ireland | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |