| Certificate Number | 35 | | Date Issued |
| Child Given Name | T. |
McCoy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Jul 1880 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | John |
McCoy | Father's Surname |
| Father's Occupation | Merchant | American | Father's Nationality |
| Father's Birth Place | Virginia | 27 | Father's Age |
| Mother's Given Name | Anna | Odonnell | Mother's Maiden Name |
| Mother's Surname | McCoy | | Mother's Residence |
| Mother's Nationality | Englishman | England | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo Frazee | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Frazee | Colo IA | Certificate Signer's Address |
| Returned by Name | 'By mail' | | |