| Certificate Number | 133 | | Date Issued |
| Child Given Name | Benjamin Avery |
Belt | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 04 Mar 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Benj F. |
Belt | Father's Surname |
| Father's Occupation | Fireman for C&NW RR | American | Father's Nationality |
| Father's Birth Place | | 25 | Father's Age |
| Mother's Given Name | Vinie A. | Dailey | Mother's Maiden Name |
| Mother's Surname | Belt | Boone Co IA | Mother's Residence |
| Mother's Nationality | American | | Mother's Birth Place |
| Mother's Age | 23 | 3 | 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 | | |