| Certificate Number | 496 | | Date Issued |
| Child Given Name | |
Chevill | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Oct 1883 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | William |
Chevill Jr. | Father's Surname |
| Father's Occupation | Laborer | English | Father's Nationality |
| Father's Birth Place | England | 23 | Father's Age |
| Mother's Given Name | Nancy J. | Broughard | Mother's Maiden Name |
| Mother's Surname | Chevill | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |