| Certificate Number | 31 | | Date Issued |
| Child Given Name | Blaine |
Corbin | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Oct 1884 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Wilbert |
Corbin | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Webster Co IA | 25 | Father's Age |
| Mother's Given Name | Ella | McKee | Mother's Maiden Name |
| Mother's Surname | Corbin | | Mother's Residence |
| Mother's Nationality | | Fayette Co IL | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.H. Rosenburg, Dr. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.H. Rosenburg, Dr. | J.H. | Certificate Signer's Address |
| Returned by Name | Rosenburg | | |