| Certificate Number | 165 | | Date Issued |
| Child Given Name | |
Smay | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 01 May 1881 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | J.A. |
Smay | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Maryland | 48 | Father's Age |
| Mother's Given Name | I.J. | Apple | Mother's Maiden Name |
| Mother's Surname | Smay | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 33 | 5 | 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 | 'mail' | | |