| Certificate Number | 941 | | Date Issued |
| Child Given Name | Earnest Dana |
Shepard | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Apr 1884 |
Gilbert Station Story Co IA | Place of Birth |
| Father's Given Name | Edward |
Shepard | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 29 | Father's Age |
| Mother's Given Name | Emma E. | Sargeant | Mother's Maiden Name |
| Mother's Surname | Shepard | Gilbert Station Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Gilbert Station IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Gilbert Station IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |