| Certificate Number | 514 | | Date Issued |
| Child Given Name | |
Vandeburg | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Dec 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | David |
Vanderburg | Father's Surname |
| Father's Occupation | Cook | American | Father's Nationality |
| Father's Birth Place | New York | 27 | Father's Age |
| Mother's Given Name | Lowie | Robinson | Mother's Maiden Name |
| Mother's Surname | Vanderburg | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Nevada Story Co IA | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler | Nevada IA | Certificate Signer's Address |
| Returned by Name | Lewis Schooler | | |