| Certificate Number | 167 | | Date Issued |
| Child Given Name | Marietta |
Massey | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Jul 1890 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | S.F. |
Massey | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 37 | Father's Age |
| Mother's Given Name | Marietta | Short | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 29 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |