| Certificate Number | 957 | | Date Issued |
| Child Given Name | |
Dool | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 May 1884 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Robt |
Dool | Father's Surname |
| Father's Occupation | Harness Maker | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 23 | Father's Age |
| Mother's Given Name | Ada | Bishop | Mother's Maiden Name |
| Mother's Surname | Dool | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |