| Certificate Number | 872 | | Date Issued |
| Child Given Name | Fred Elmer |
Stultz | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Feb 1884 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo H. |
Stultz | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 26 | Father's Age |
| Mother's Given Name | Agnes A. | James | Mother's Maiden Name |
| Mother's Surname | Stultz | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo. Stitzell | | |