| Certificate Number | 476 | | Date Issued |
| Child Given Name | |
Davis | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Jan 1887 |
| Place of Birth |
| Father's Given Name | John |
Davis | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 37 | Father's Age |
| Mother's Given Name | Mary Bell | Smith | Mother's Maiden Name |
| Mother's Surname | Davis | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Monk | | |