| Certificate Number | 167 | | Date Issued |
| Child Given Name | George M |
Posegate | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 May 1881 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo. W. |
Posegate | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 24 | Father's Age |
| Mother's Given Name | Sarah Jane | Illingsworth | Mother's Maiden Name |
| Mother's Surname | Posegate | Kelley Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hays | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hays | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hays | | |