| Certificate Number | 873 | | Date Issued |
| Child Given Name | |
Stephens | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Jul 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | T.H. |
Stephens | Father's Surname |
| Father's Occupation | Merchant | American | Father's Nationality |
| Father's Birth Place | Ohio | 36 | Father's Age |
| Mother's Given Name | Francis A. | Foster | Mother's Maiden Name |
| Mother's Surname | Stephens | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo., Dr. Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo., Dr. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo., Dr. Stitzell | | |