| Certificate Number | 277 | | Date Issued |
| Child Given Name | |
White | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Jan 1886 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | F.H. |
White | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 33 | Father's Age |
| Mother's Given Name | K.A. | Fultz | Mother's Maiden Name |
| Mother's Surname | White | | Mother's Residence |
| Mother's Nationality | | Missouri | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |