| Certificate Number | 289 | | Date Issued |
| Child Given Name | |
Shearer | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Sep 1885 |
| Place of Birth |
| Father's Given Name | Joseph |
Shearer | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 38 | Father's Age |
| Mother's Given Name | Lena | | Mother's Maiden Name |
| Mother's Surname | Shearer | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 24 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |