| Certificate Number | 5 | | Date Issued |
| Child Given Name | Charles |
Davis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Sep 1888 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | John L. |
Davis | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 29 | Father's Age |
| Mother's Given Name | Bell | Smith | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 26 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Mary F. Belcher | Nevada IA | Medical Attendant's Address |