| Certificate Number | 319 | | Date Issued |
| Child Given Name | |
Whittaker | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 22 Jan 1882 |
| Place of Birth |
| Father's Given Name | Thomas |
Whittaker | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Virginia | 45 | Father's Age |
| Mother's Given Name | Harriet | McConnell | Mother's Maiden Name |
| Mother's Surname | Whittaker | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 41 | 7 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Monk M.D. | | |