| Certificate Number | 253 | | Date Issued |
| Child Given Name | Carl Oley |
Gibson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Sep 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | John |
Gibson | Father's Surname |
| Father's Occupation | Labor | | Father's Nationality |
| Father's Birth Place | Illinois | 22 | Father's Age |
| Mother's Given Name | Laura | Moore | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | New Johnson | Nevada IA | Medical Attendant's Address |