| Certificate Number | 40 | | Date Issued |
| Child Given Name | Zetta |
Scott | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Dec 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | J.D. |
Scott | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Scotland | 39 | Father's Age |
| Mother's Given Name | Zetta | Cassidy | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |