| Certificate Number | 382 | | Date Issued |
| Child Given Name | |
Carhart | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 06 Feb 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | James R. |
Carhart | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 38 | Father's Age |
| Mother's Given Name | Adeline | Huling | Mother's Maiden Name |
| Mother's Surname | Carhart | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wisconson | Mother's Birth Place |
| Mother's Age | 35 | 6 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar M.D. | | |