| Certificate Number | 133 | | Date Issued |
| Child Given Name | |
Bone | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 May 1885 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | A.K. |
Bone | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Mother's Surname | | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Age | | 3 | 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 | | |