| Certificate Number | 383 | | Date Issued |
| Child Given Name | Donald |
Dana | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Jun 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Frank |
Dana | Father's Surname |
| Father's Occupation | Atty | American | Father's Nationality |
| Father's Birth Place | Nevada IA | 24 | Father's Age |
| Mother's Given Name | Effie Lura | Whipple | Mother's Maiden Name |
| Mother's Surname | Dana | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Marion IA | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Fauds M.D. | | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Fauds M.D. | | Certificate Signer's Address |
| Returned by Name | P.W. Fauds M.D. | | |