| Certificate Number | 731 | | Date Issued |
| Child Given Name | John Mathias |
Hand | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Aug 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Wm T. |
Hand | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Ohio | 30 | Father's Age |
| Mother's Given Name | T.J. | Sheply | Mother's Maiden Name |
| Mother's Surname | Hand | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |