| Certificate Number | 101 | | Date Issued |
| Child Given Name | |
Silliman | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 21 Dec 1880 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Rothmer J. |
Silliman | Father's Surname |
| Father's Occupation | Grain & Lumber Merchant | American | Father's Nationality |
| Father's Birth Place | Whiteside Co IL | 42 | Father's Age |
| Mother's Given Name | Lucy J. | Newman | Mother's Maiden Name |
| Mother's Surname | Silliman | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Carroll Co IA | Mother's Birth Place |
| Mother's Age | 38 | 5 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |