| Certificate Number | 866 | | Date Issued |
| Child Given Name | Bessie R. |
McNichols | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Feb 1884 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Michael |
McNichols | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 36 | Father's Age |
| Mother's Given Name | Hannah | Cary | Mother's Maiden Name |
| Mother's Surname | McNichols | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wisconson | Mother's Birth Place |
| Mother's Age | 29 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |