| Certificate Number | 504 | | Date Issued |
| Child Given Name | Phillip Samuel |
Flack | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Mar 1887 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | F.A. |
Flack | Father's Surname |
| Father's Occupation | Barber | | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Carrie E. | Statler | Mother's Maiden Name |
| Mother's Surname | Flack | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |