| Certificate Number | 286 | | Date Issued |
| Child Given Name | Catherine |
Golly | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Oct 1883 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | Wm. H. |
Golly | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 37 | Father's Age |
| Mother's Given Name | Jane | Perry | Mother's Maiden Name |
| Mother's Surname | Gooly | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | English | England | Mother's Birth Place |
| Mother's Age | 36 | 5 | Number of Child This Mother |
| Certificate Signer's Name | W.H. Golly | Lincoln Twp IA | Certificate Signer's Address |
| Returned by Name | W.H. Golly | | |