| Certificate Number | 197 | | Date Issued |
| Child Given Name | Ross E. |
White | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Jun 1889 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | A.A. |
White | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 21 | Father's Age |
| Mother's Given Name | Mary | Brodie | Mother's Maiden Name |
| Mother's Surname | | Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |