| Certificate Number | 291 | | Date Issued |
| Child Given Name | |
White | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 26 Oct 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | J.W. |
White | Father's Surname |
| Father's Occupation | Merchant | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 37 | Father's Age |
| Mother's Given Name | Eliza | Hogman | 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 | 32 | 5 | Number of Child This Mother |
| Certificate Signer's Name | Geo. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo. Stitzell | | |