| Certificate Number | 560 | | Date Issued |
| Child Given Name | Edith Amy |
Stevens | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Jan 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Wm. I. |
Stevens | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | | 34 | Father's Age |
| Mother's Given Name | Clara C. | Spencer | Mother's Maiden Name |
| Mother's Surname | Stevens | Nevada Story Co IA | Mother's Residence |
| Mother's Age | 35 | 6 | 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 | | |