| Certificate Number | 383 | | Date Issued |
| Child Given Name | |
Worsley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Sep 1886 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Theodore P. |
Worsley | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | England | 28 | Father's Age |
| Mother's Given Name | Elfa | Worsley | Mother's Maiden Name |
| Mother's Surname | Lockridge | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Nevada Story Co IA | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlain | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | H.D. Chamberlain | Nevada IA | Certificate Signer's Address |
| Returned by Name | H.D. Chamberlain | | |