| Certificate Number | 26 | | Date Issued |
| Child Given Name | |
Booher | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Nov 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | John |
Booher | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 22 | Father's Age |
| Mother's Given Name | Ella | Elzy | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Marshall Co IA | Mother's Birth Place |
| Mother's Age | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | L.C., Mrs. Batt | Nevada IA | Medical Attendant's Address |