| Certificate Number | 155 | | Date Issued |
| Child Given Name | Nillie |
Miller | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 18 Apr 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | William Alexander |
Miller | Father's Surname |
| Father's Occupation | Clerk | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 39 | Father's Age |
| Mother's Given Name | Maggie Emma | Shaman | Mother's Maiden Name |
| Mother's Surname | Miller | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 35 | 5 | 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 | | |