| Certificate Number | 272 | | Date Issued |
| Child Given Name | |
Dayton | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Mar 1886 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | E.A. |
Dayton | Father's Surname |
| Father's Occupation | Jewelist | | Father's Nationality |
| Father's Birth Place | Illinois | 29 | Father's Age |
| Mother's Given Name | Mamie S. | King | Mother's Maiden Name |
| Mother's Surname | Dayton | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzall | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | George Stitzall | Nevada IA | Certificate Signer's Address |
| Returned by Name | George Stitzall | | |