| Certificate Number | 201 | | Date Issued |
| Child Given Name | Rollin Benjamin |
Boitnott | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Sep 1890 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank |
Berry | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 31 | Father's Age |
| Mother's Given Name | Urissa | Wilson | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 27 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlain | Nevada IA | Medical Attendant's Address |