| Certificate Number | 615 | | Date Issued |
| Child Given Name | |
Schooler | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Apr 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Lewis |
Schooler | Father's Surname |
| Father's Occupation | Physician | American | Father's Nationality |
| Father's Birth Place | Indiana | 35 | Father's Age |
| Mother's Given Name | Alice J. | Hoskins | Mother's Maiden Name |
| Mother's Surname | Schooler | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | New Hampshire | Mother's Birth Place |
| Mother's Age | 28 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler | Nevada IA | Certificate Signer's Address |
| Returned by Name | Lewis Schooler | | |