| Certificate Number | 141 | | Date Issued |
| Child Given Name | Arthur Burton |
Spencer | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Nov 1884 |
| Place of Birth |
| Father's Given Name | D.H. |
Spencer | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 44 | Father's Age |
| Mother's Given Name | Sarah | Skinner | Mother's Maiden Name |
| Mother's Surname | Spencer | | Mother's Residence |
| Mother's Nationality | English | England | Mother's Birth Place |
| Mother's Age | 35 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Abbey M. Penn | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Abbey M. Penn | Nevada IA | Certificate Signer's Address |
| Returned by Name | Abbey M. Penn | | |