| Certificate Number | 147 | | Date Issued |
| Child Given Name | Jas. |
Throckmorton | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 May 1890 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | J.S. |
Throckmorton | Father's Surname |
| Father's Occupation | Preacher | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 35 | Father's Age |
| Mother's Given Name | Flora | Marshall | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 33 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |