| Certificate Number | 199 | | Date Issued |
| Child Given Name | John Hoyman |
White | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 10 Jul 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | John W. |
White | Father's Surname |
| Father's Occupation | Merchant | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 30 | Father's Age |
| Mother's Given Name | Elizabeth | Hay | Mother's Maiden Name |
| Mother's Surname | White | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Butt | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Mrs. Butt | Nevada IA | Certificate Signer's Address |
| Returned by Name | Mrs. Butt | | |