| Certificate Number | 727 | | Date Issued |
| Child Given Name | Mervin Mathews |
Whitney | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Jul 1883 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Mervin A. |
Whitney | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New York | 28 | Father's Age |
| Mother's Given Name | Jennie H. | Whitney | Mother's Maiden Name |
| Mother's Surname | Mathew | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 29 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo. Stitzell | | |