| Certificate Number | 316 | | Date Issued |
| Child Given Name | |
McIntosh | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | |
| Place of Birth |
| Father's Given Name | Henry |
McIntosh | Father's Surname |
| Father's Occupation | Drayman | | Father's Nationality |
| Mother's Surname | McIntosh | Nevada Story Co IA | Mother's Residence |
| Mother's Age | | 5 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Monk M.D. | | |