| Certificate Number | 41 | | Date Issued |
| Child Given Name | David O. |
Hines | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Nov 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | L.W. |
Hines | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Ohio | 59 | Father's Age |
| Mother's Given Name | Ella | Yazel | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 33 | 7 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |