| Certificate Number | 128 | | Date Issued |
| Child Given Name | Thomas |
Oleary | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 24 Feb 1881 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Dennis |
Oleary | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 38 | Father's Age |
| Mother's Given Name | Mary | Grady | Mother's Maiden Name |
| Mother's Surname | Oleary | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Irish | Ireland | Mother's Birth Place |
| Mother's Age | 38 | 7 | Number of Child This Mother |
| Medical Attendant's Name | L.W. Thomas | Edenville | Medical Attendant's Address |
| Certificate Signer's Name | L.W. Thomas | Edenville | Certificate Signer's Address |
| Returned by Name | 'By mail' | | |