| Certificate Number | 201 | | Date Issued |
| Child Given Name | Chloie Rowena |
Dalph | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 20 Jun 1881 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Charles |
Dalph | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 29 | Father's Age |
| Mother's Given Name | Mary C. | Wilhide | Mother's Maiden Name |
| Mother's Surname | Dalph | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 21 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |