| Certificate Number | 264 | | Date Issued |
| Child Given Name | |
Burns | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Nevada | Place of Birth |
| Father's Given Name | Patrick |
Burns | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Ireland | 22 | Father's Age |
| Mother's Given Name | Melissa | | Mother's Maiden Name |
| Mother's Surname | Burns | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 33 | 7 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Smith M.D. | Nevada IA | Medical Attendant's Address |