| Certificate Number | 685 | | Date Issued |
| Child Given Name | Marian Willm |
Cure | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Jul 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Joseph |
Cure | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Indiana | 29 | Father's Age |
| Mother's Given Name | Rachel A. | Clark | Mother's Maiden Name |
| Mother's Surname | Cure | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 31 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.N. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.N. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.N. Munk | | |