| Certificate Number | 611 | | Date Issued |
| Child Given Name | Nettie |
Dool | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Aug 1887 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | R.A. |
Dool | Father's Surname |
| Father's Occupation | Harness Maker | | Father's Nationality |
| Father's Birth Place | Canada | 27 | Father's Age |
| Mother's Given Name | I.M. | Bishop | Mother's Maiden Name |
| Mother's Surname | Dool | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 29 | 3 | Number of Child This Mother |
| Medical Attendant's Name | A.G., Mrs. Torrence | Zearing IA | Medical Attendant's Address |