| Certificate Number | 172 | | Date Issued |
| Child Given Name | Charles |
Hoag | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Jan 1890 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Charles E. |
Hoag | Father's Surname |
| Father's Occupation | Dentist | | Father's Nationality |
| Father's Birth Place | New York | 38 | Father's Age |
| Mother's Given Name | Carrie | Herrick | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 33 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |