| Certificate Number | 234 | | Date Issued |
| Child Given Name | Orville O. |
Moore | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Aug 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Orrin |
Moore | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Jackson Co IA | 34 | Father's Age |
| Mother's Given Name | Maggie | Kunkel | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Jo Davis Co IL | Mother's Birth Place |
| Mother's Age | 29 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Mary, Mrs. Johnson | Nevada IA | Medical Attendant's Address |