| Certificate Number | 98 | | Date Issued |
| Child Given Name | Ethel |
Chamberlain | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Feb 1890 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | H.Dewey |
Chamberlain | Father's Surname |
| Father's Occupation | Physician | | Father's Nationality |
| Father's Birth Place | Vermont | 41 | Father's Age |
| Mother's Given Name | Mary C. | Hoag | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Vermont | Mother's Birth Place |
| Mother's Age | 41 | 4 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlain | Nevada IA | Medical Attendant's Address |