| Certificate Number | 156 | | Date Issued |
| Child Given Name | |
Pervis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Aug 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Theodore |
Pervis | Father's Surname |
| Father's Occupation | Saloon Keeper | | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Susan | Seal | Mother's Maiden Name |
| Mother's Surname | Pervis | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merideth | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merideth | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Merideth | | |