| Certificate Number | 687 | | Date Issued |
| Child Given Name | |
Shockley | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Jul 1883 |
| Place of Birth |
| Father's Given Name | I.A. |
Shockley | Father's Surname |
| Father's Occupation | Tile Burner | | Father's Nationality |
| Father's Birth Place | | 36 | Father's Age |
| Mother's Given Name | Carrie | Mullen | Mother's Maiden Name |
| Mother's Surname | Shockley | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |