| Certificate Number | 1020 | | Date Issued |
| Child Given Name | Nector |
Beverly | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Jun 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | C.A. |
Beverly | Father's Surname |
| Father's Occupation | Physician | American | Father's Nationality |
| Father's Birth Place | Illinois | 33 | Father's Age |
| Mother's Given Name | Mattie M. | Grier | Mother's Maiden Name |
| Mother's Surname | Beverly | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 31 | 5 | Number of Child This Mother |
| Medical Attendant's Name | C.A., Dr. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A., Dr. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A., Dr. Beverly | | |