| Certificate Number | 249 | | Date Issued |
| Child Given Name | |
Ozmun | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Sep 1890 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | W.H. |
Ozmun | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 43 | Father's Age |
| Mother's Given Name | | Smith | Mother's Maiden Name |
| Mother's Surname | | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 29 | 5 | Number of Child This Mother |
| Medical Attendant's Name | A.P. Edgar | Collins IA | Medical Attendant's Address |