| Certificate Number | 108 | | Date Issued |
| Child Given Name | |
Simser | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Mar 1888 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Nick |
Simser | Father's Surname |
| Father's Occupation | Blacksmith | | Father's Nationality |
| Father's Birth Place | Canada | 44 | Father's Age |
| Mother's Given Name | Ettie B. | Miller | Mother's Maiden Name |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 28 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlain | Nevada IA | Medical Attendant's Address |