| Certificate Number | 507 | | Date Issued |
| Child Given Name | |
Shinkle | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Nov 1882 |
| Place of Birth |
| Father's Given Name | J.T. |
Shinkle | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | Nettie | Crouch | Mother's Maiden Name |
| Mother's Surname | Shinkle | O'Brien Co IA | Mother's Residence |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper M.D. | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper M.D. | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper M.D. | | |