| Certificate Number | 179 | | Date Issued |
| Child Given Name | Walten |
Golly | Child Surname |
| Child Sex | Male |
A | Child Race |
| Date of Birth | 12 Apr 1881 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | W.H. |
Golly | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New York | | Father's Age |
| Mother's Given Name | Jane | Perry | Mother's Maiden Name |
| Mother's Surname | Golly | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | England | Mother's Birth Place |
| Mother's Age | 33 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Hurst | | Medical Attendant's Address |
| Certificate Signer's Name | W.H. Golly | Lincoln Twp IA | Certificate Signer's Address |
| Returned by Name | W.H. Golly | | |