| Certificate Number | 92 | | Date Issued |
| Child Given Name | Debore Jane |
Ormsby | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 11 Dec 1880 |
At Residence of Mr. Ormsby | Place of Birth |
| Father's Given Name | Robert L. |
Ormsby | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New York | 56 | Father's Age |
| Mother's Given Name | Mary R. | Bates | Mother's Maiden Name |
| Mother's Surname | Ormsby | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 37 | 8 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |