| Certificate Number | 377 | | Date Issued |
| Child Given Name | |
Chitty | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Aug 1886 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Eley |
Chitty | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Carrie | White | Mother's Maiden Name |
| Mother's Surname | Chitty | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk | E.H. | Certificate Signer's Address |
| Returned by Name | Monk | | |