| Certificate Number | 264 | | Date Issued |
| Child Given Name | Bernice |
Halley | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Nov 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Wilson |
Halley | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 60 | Father's Age |
| Mother's Given Name | Rozenia | | Mother's Maiden Name |
| Mother's Surname | Halley | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | Swiss | Switzerland | Mother's Birth Place |
| Mother's Age | 34 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Butt | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Mrs. Butt | Nevada IA | Certificate Signer's Address |
| Returned by Name | Mrs. Butt | | |