| Certificate Number | 17 | | Date Issued |
| Child Given Name | Bessie Maude |
Boyd | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 06 Jul 1880 |
Residence of G.W. Boyd | Place of Birth |
| Father's Given Name | Geo W. |
Boyd | Father's Surname |
| Father's Occupation | Butcher | American | Father's Nationality |
| Father's Birth Place | | 36 | Father's Age |
| Mother's Given Name | Senla Frank | Bates | Mother's Maiden Name |
| Mother's Surname | Boyd | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |