| Certificate Number | 4 | | Date Issued |
| Child Given Name | Fred |
French | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Sep 1889 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | J.S. |
French | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Indiana | 59 | Father's Age |
| Mother's Given Name | E.F. | Bishop | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Michigan | Mother's Birth Place |
| Mother's Age | 38 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |