| Certificate Number | 1053 | | Date Issued |
| Child Given Name | Walter M. |
Hulse | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Sep 1884 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | F.M. |
Hulse | Father's Surname |
| Father's Birth Place | Laport IN | 35 | Father's Age |
| Mother's Given Name | Candance A. | Baldwin | Mother's Maiden Name |
| Mother's Surname | Hulse | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Laport IN | Mother's Birth Place |
| Mother's Age | 23 | 1 | 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 | | |