| Certificate Number | 503 | | Date Issued |
| Child Given Name | Benj F. |
Dolph | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Dec 1886 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Elmore |
Dolph | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | Achsah | Kenney | Mother's Maiden Name |
| Mother's Surname | Dolph | Collins Story Co IA | Mother's Residence |
| Mother's Age | | 8 | 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 | | |