| Certificate Number | 721 | | Date Issued |
| Child Given Name | |
Robinson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Aug 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Henry |
Robinson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | H. | | Mother's Maiden Name |
| Mother's Surname | Robinson | Nevada Story Co IA | Mother's Residence |
| Mother's Age | | 7 | 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 | | |