| Certificate Number | 174 | | Date Issued |
| Child Given Name | |
Zerba | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 09 May 1881 |
Mrs. Bixby's | Place of Birth |
| Father's Given Name | Harry |
Zerba | Father's Surname |
| Father's Occupation | Carpenter | American | Father's Nationality |
| Father's Birth Place | Ohio | 32 | Father's Age |
| Mother's Given Name | Alice | Bixby | Mother's Maiden Name |
| Mother's Surname | Zerba | Marshalltown Marshall Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |