| Certificate Number | 207 | | Date Issued |
| Child Given Name | |
Foster | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 30 Jul 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | George P. |
Foster | Father's Surname |
| Father's Occupation | Stock Dealer | U.S. | Father's Nationality |
| Father's Birth Place | Lenoway Co MI | 32 | Father's Age |
| Mother's Given Name | Sarah | Blosser | Mother's Maiden Name |
| Mother's Surname | Foster | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | U.S. | Toledo Tama Co IA | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J. Daugherty | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J. Daugherty | Colo IA | Certificate Signer's Address |
| Returned by Name | J. Daugherty | | |