| Certificate Number | 37 | | Date Issued |
| Child Given Name | Forrest |
McCallom | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Nov 1888 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Frank |
McCallom | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ireland | 36 | Father's Age |
| Mother's Given Name | Ida | Kent | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Ogle Co IL | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Roberts | Colo IA | Medical Attendant's Address |