| Certificate Number | 67 | | Date Issued |
| Child Given Name | William Arthur |
Worsley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 16 Jan 1885 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Theodore |
Worsley | Father's Surname |
| Father's Occupation | Music Dealer | English | Father's Nationality |
| Father's Birth Place | England | 24 | Father's Age |
| Mother's Given Name | Ella | Lockridge | Mother's Maiden Name |
| Mother's Surname | Worsley | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Nevada Story Co IA | Mother's Birth Place |
| Mother's Age | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.E. Scott | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.E. Scott | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.E. Scott | | |