| Certificate Number | 301 | | Date Issued |
| Child Given Name | Leon Eugene |
Stevens | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Sep 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | W.I. |
Stevens | Father's Surname |
| Father's Occupation | Mechanic | | Father's Nationality |
| Father's Birth Place | Ohio | 41 | Father's Age |
| Mother's Given Name | C.J. | Spencer | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 44 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Spencer | Nevada IA | Medical Attendant's Address |
| Returned by Name | J.A. Jeffry | | |