| Certificate Number | 463 | | Date Issued |
| Child Given Name | Jasper |
Emerson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Nov 1886 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | Myron |
Emerson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 24 | Father's Age |
| Mother's Given Name | Nettie | Hallowell | Mother's Maiden Name |
| Mother's Surname | Emerson | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Johnson | | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |