| Certificate Number | 728 | | Date Issued |
| Child Given Name | Earl Bates |
Boyd | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Aug 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | G.W. |
Boyd | Father's Surname |
| Father's Occupation | Butcher | American | Father's Nationality |
| Father's Birth Place | Tennessee | 40 | Father's Age |
| Mother's Given Name | S.F. | Bates | Mother's Maiden Name |
| Mother's Surname | Boyd | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 30 | 4 | 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 | | |