| Certificate Number | 243 | | Date Issued |
| Child Given Name | |
Whitney | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Sep 1890 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | M.N. |
Whitney | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 38 | Father's Age |
| Mother's Given Name | Nancy J. | Mathews | Mother's Maiden Name |
| Mother's Surname | | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 37 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Jeffrey | Nevada IA | Medical Attendant's Address |