| Certificate Number | 133 | | Date Issued |
| Child Given Name | Hettie A. |
Withey | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Oct 1888 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | R.O. |
Withey | Father's Surname |
| Father's Occupation | Grocer | | Father's Nationality |
| Father's Birth Place | Lee Co IL | 32 | Father's Age |
| Mother's Given Name | Abby | Briggs | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 25 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |