| Certificate Number | 497 | | Date Issued |
| Child Given Name | |
Chatman | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Mar 1887 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Edwin |
Chatman | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 39 | Father's Age |
| Mother's Given Name | Belle | Dunklebarger | Mother's Maiden Name |
| Mother's Surname | Chatman | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 39 | 7 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Jeffrey | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.A. Jeffrey | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.A. Jeffrey | | |