| Certificate Number | 357 | | Date Issued |
| Child Given Name | |
Fox | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 03 Apr 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | John Young |
Fox | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Iowa | 25 | Father's Age |
| Mother's Given Name | Rosa L. | Cassall | Mother's Maiden Name |
| Mother's Surname | Fox | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 16 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler | Nevada IA | Certificate Signer's Address |
| Returned by Name | Lewis Schooler | | |