| Certificate Number | 192 | | Date Issued |
| Child Given Name | |
Davis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Jul 1890 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Herbert M. |
Davis | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 28 | Father's Age |
| Mother's Given Name | Carrie L. | Nelson | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Albert Richmond | Ames IA | Medical Attendant's Address |
| Returned by Name | E.H. Monk | | |