| Certificate Number | 200 | | Date Issued |
| Child Given Name | |
Hayden | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 12 Jul 1881 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Christopher C. |
Hayden | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 33 | Father's Age |
| Mother's Given Name | Amanda A. | McArthur | Mother's Maiden Name |
| Mother's Surname | Hayden | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 30 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |