| Certificate Number | 136 | | Date Issued |
| Child Given Name | |
Shugart | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 May 1890 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Shugart | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Illinois | 25 | Father's Age |
| Mother's Given Name | Edith | Banks | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlain | Nevada IA | Medical Attendant's Address |