| Certificate Number | 420 | | Date Issued |
| Child Given Name | Mary E. |
Mewhister | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Aug 1886 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Andrew W. |
Mewhister | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 35 | Father's Age |
| Mother's Given Name | Thersa | Stanley | Mother's Maiden Name |
| Mother's Surname | Mewhister | | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 29 | 3 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | George Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | George Stitzell | | |