| Certificate Number | 502 | | Date Issued |
| Child Given Name | |
Mullen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 23 Nov 1882 |
| Place of Birth |
| Father's Given Name | Albert |
Mullen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | | 24 | Father's Age |
| Mother's Surname | Mullen | | Mother's Residence |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk M.D. | | |