| Certificate Number | 16 | | Date Issued |
| Child Given Name | |
Sutherland | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Aug 1880 4 OClock |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | David E. |
Sutherland | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 36 | Father's Age |
| Mother's Given Name | Dora B. | Cook | Mother's Maiden Name |
| Mother's Surname | Sutherland | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 38 | 7 | Number of Child This Mother |
| Medical Attendant's Name | E. Henri Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E. Henri Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E. Henri Munk | | |