| Certificate Number | 802 | | Date Issued |
| Child Given Name | George S. |
Townsend | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Oct 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | James W.L. |
Townsend | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | | 22 | Father's Age |
| Mother's Given Name | Martha Jane | Mitchell | Mother's Maiden Name |
| Mother's Surname | Townsend | Nevada Story Co IA | Mother's Residence |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |