| Certificate Number | 420 | | Date Issued |
| Child Given Name | Garfield |
Dolph | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Aug 1882 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Elmer |
Dolph | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 37 | Father's Age |
| Mother's Given Name | Ann | Kennedy | Mother's Maiden Name |
| Mother's Surname | Dolph | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 28 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |