| Certificate Number | 145 | | Date Issued |
| Child Given Name | |
Day | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 May 1888 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo. |
Day | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 39 | Father's Age |
| Mother's Given Name | Annie | Apple | Mother's Maiden Name |
| Mother's Surname | Day | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |