| Certificate Number | 65 | | Date Issued |
| Child Given Name | |
Sherman | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Jan 1890 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Ed. |
Sherman | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Iowa | 36 | Father's Age |
| Mother's Given Name | Nettie | Reed | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 27 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Massie | Nevada IA | Medical Attendant's Address |