| Certificate Number | 121 | | Date Issued |
| Child Given Name | Minnie Maud |
Doal | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 11 Feb 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Alfred L. |
Doal | Father's Surname |
| Father's Occupation | Laborer | Canada | Father's Nationality |
| Father's Birth Place | | 22 | Father's Age |
| Mother's Given Name | Mary Ann | Wier | Mother's Maiden Name |
| Mother's Surname | Doal | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | Canada | | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |