| Certificate Number | 446 | | Date Issued |
| Child Given Name | |
Henry | Child Surname |
| Child Sex | |
W | Child Race |
| Date of Birth | 10 Jul 1882 |
| Place of Birth |
| Father's Given Name | James |
Henry | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Nevada Twp Story Co IA | | Father's Age |
| Mother's Given Name | James, Mrs. | | Mother's Maiden Name |
| Mother's Surname | Henry | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Age | | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Monk M.D. | | |