| Certificate Number | 201 | | Date Issued |
| Child Given Name | Ottie Trigo |
Deal | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Aug 1885 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | Milton |
Deal | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 30 | Father's Age |
| Mother's Given Name | Effie A. | Frego | Mother's Maiden Name |
| Mother's Surname | Deal | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.C. Waterman | St. Anthony IA | Medical Attendant's Address |
| Certificate Signer's Name | J.C. Waterman | St. Anthony IA | Certificate Signer's Address |
| Returned by Name | J.C. Waterman | | |