| Certificate Number | 184 | | Date Issued |
| Child Given Name | |
Davis | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Aug 1885 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Davis | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 25 | Father's Age |
| Mother's Given Name | Isabella | Smith | Mother's Maiden Name |
| Mother's Surname | Davis | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 22 | 3 | Number of Child This Mother |
| Medical Attendant's Name | I., Mrs. & John, Mrs. KeKorn & Simmons | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Misick | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Misick | | |