| Certificate Number | 123 | | Date Issued |
| Child Given Name | |
Friend | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo. R. |
Friend | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 28 | Father's Age |
| Mother's Given Name | Mary J. | Chitty | Mother's Maiden Name |
| Mother's Surname | Friend | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 28 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Frazee | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Frazee | Colo IA | Certificate Signer's Address |
| Returned by Name | Geo. Frazee | | |