| Certificate Number | 379 | | Date Issued |
| Child Given Name | |
Halsey | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 25 Feb 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | W. |
Halsey | Father's Surname |
| Father's Occupation | Butcher | American | Father's Nationality |
| Father's Birth Place | Illinois | 31 | Father's Age |
| Mother's Given Name | Laura | Purkeiser | Mother's Maiden Name |
| Mother's Surname | Halsey | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 21 | 4 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar M.D. | | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar M.D. | | Certificate Signer's Address |
| Returned by Name | P.W. Farrar M.D. | | |