| Certificate Number | 857 | | Date Issued |
| Child Given Name | |
Shenkle | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Jan 1884 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | W.C. |
Shinkle | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 29 | Father's Age |
| Mother's Given Name | Arsula A. | Henderson | Mother's Maiden Name |
| Mother's Surname | Shenkle | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 3 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper | | |