| Certificate Number | 80 | | Date Issued |
| Child Given Name | |
Frazier | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Nov 1880 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | James S. |
Frazier | Father's Surname |
| Father's Occupation | Atty at Law | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | | Father's Age |
| Mother's Given Name | Anne | Green | Mother's Maiden Name |
| Mother's Surname | Frazier | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Maryland | Mother's Birth Place |
| Mother's Age | | 3 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | George Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | George Stitzell | | |