| Certificate Number | 86 | | Date Issued |
| Child Given Name | Warren E. |
Jeffrey | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Dec 1887 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | A.T. |
Jeffrey | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Father's Birth Place | Wabash Co IN | 38 | Father's Age |
| Mother's Given Name | Nellie J. | Dungan | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Henry Co IA | Mother's Birth Place |
| Mother's Age | 31 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Jeffrey | Nevada IA | Medical Attendant's Address |