| Certificate Number | 838 | | Date Issued |
| Child Given Name | Vera Lavina |
Childs | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Dec 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Willy Wilson |
Childs | Father's Surname |
| Father's Occupation | Liveryman | American | Father's Nationality |
| Father's Birth Place | Nevada Story Co IA | 22 | Father's Age |
| Mother's Given Name | Nora S. | Foot | Mother's Maiden Name |
| Mother's Surname | Childs | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Story City Story Co IA | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | George Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | George Stitzell | | |