| Certificate Number | 40 | | Date Issued |
| Child Given Name | |
Wilson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Sep 1880 2PM |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Samuel M. |
Wilson | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Ohio | 36 | Father's Age |
| Mother's Given Name | Jane Shelly | | Mother's Maiden Name |
| Mother's Surname | Wilson | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Henri Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Henri Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | Henri Munk | | |