| Certificate Number | 221 | | Date Issued |
| Child Given Name | Patrick David |
Fitzgerald | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 02 Aug 1881 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Fitzgerald | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | | 33 | Father's Age |
| Mother's Given Name | Kate | Mulcahy | Mother's Maiden Name |
| Mother's Surname | Fitzgerald | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Age | 28 | 3 | 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 | | |