| Certificate Number | 400 | | Date Issued |
| Child Given Name | |
Rogers | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 May 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Ashley |
Rogers | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Mother's Given Name | Emma | Churchell | Mother's Maiden Name |
| Mother's Surname | Rogers | Nevada Story Co IA | Mother's Residence |
| Mother's Age | | 1 | Number of Child This Mother |
| Certificate Signer's Name | Abbey M. Penn | | Certificate Signer's Address |
| Returned by Name | Abbey M. Penn | | |