| Certificate Number | 939 | | Date Issued |
| Child Given Name | Geo |
Foster | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 May 1884 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Geo R. |
Foster | Father's Surname |
| Father's Occupation | Cattle Dealer | American | Father's Nationality |
| Father's Birth Place | Michigan | 35 | Father's Age |
| Mother's Given Name | Sarah A. | Blosser | Mother's Maiden Name |
| Mother's Surname | Foster | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 29 | 4 | 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 | | |