| Certificate Number | 112 | | Date Issued |
| Child Given Name | Ed K. |
Humphrey | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Feb 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | P.D. |
Humphrey | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 64 | Father's Age |
| Mother's Given Name | Kate | Kinsell | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 38 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |