| Certificate Number | 399 | | Date Issued |
| Child Given Name | Horace Mitchell |
Horton | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Dec 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | John |
Horton | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 62 | Father's Age |
| Mother's Given Name | Maria Louisa | Perkins | Mother's Maiden Name |
| Mother's Surname | Horton | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 42 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Abby M. Penn | | Medical Attendant's Address |
| Certificate Signer's Name | Abby M. Penn | | Certificate Signer's Address |
| Returned by Name | Abby M. Penn | | |