| Certificate Number | 230 | | Date Issued |
| Child Given Name | Edna Velora |
Funk | Child Surname |
| Child Sex | Female |
A | Child Race |
| Date of Birth | 16 Sep 1881 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | C.A. |
Funk | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Edith R. | McCord | Mother's Maiden Name |
| Mother's Surname | Funk | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Boggess | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Boggess | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.W. Boggess | | |