| Certificate Number | 201 | | Date Issued |
| Child Given Name | |
McCarthy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Jun 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | C.G. |
McCarthy | Father's Surname |
| Father's Occupation | Co. Auditor | | Father's Nationality |
| Father's Birth Place | Canada | 46 | Father's Age |
| Mother's Given Name | Laura A. | Barnes | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Scott Co IA | Mother's Birth Place |
| Mother's Age | 42 | 5 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlin | Nevada IA | Medical Attendant's Address |