| Certificate Number | 546 | | Date Issued |
| Child Given Name | |
Will | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 May 1887 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Albert M. |
Will | Father's Surname |
| Father's Occupation | Blacksmith | | Father's Nationality |
| Father's Birth Place | Stuben Co IN | 26 | Father's Age |
| Mother's Given Name | Maggie | Tetwiler | Mother's Maiden Name |
| Mother's Surname | Will | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 21 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Jeffrey | Nevada IA | Medical Attendant's Address |