| Certificate Number | 285 | | Date Issued |
| Child Given Name | |
Shurgart | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Sep 1889 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | C.J. |
Shugart | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Illinois | 23 | Father's Age |
| Mother's Given Name | Ida F. | Sutherland | Mother's Maiden Name |
| Mother's Surname | | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |