| Certificate Number | 140 | | Date Issued |
| Child Given Name | George Andrew |
Williams | Child Surname |
| Child Sex | Male |
A | Child Race |
| Date of Birth | 11 Mar 1881 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Lewis |
Williams | Father's Surname |
| Father's Occupation | Farmer | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 35 | Father's Age |
| Mother's Given Name | Julia | Barns | Mother's Maiden Name |
| Mother's Surname | Williams | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 43 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Boggess | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Boggess | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.W. Boggess | | |