| Certificate Number | 200 | | Date Issued |
| Child Given Name | |
Danskin | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Oct 1885 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo |
Danskin | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 50 | Father's Age |
| Mother's Given Name | Lizzie | | Mother's Maiden Name |
| Mother's Surname | Danskin | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 30 | 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 | | |