| Certificate Number | 262 | | Date Issued |
| Child Given Name | |
Jeffrey | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Mar 1886 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | A.F. |
Jeffrey | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Father's Birth Place | Indiana | 36 | Father's Age |
| Mother's Given Name | Nellie J. | Dungan | Mother's Maiden Name |
| Mother's Surname | Jeffrey | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F.F. Smith M.D. | Nevada IA | Medical Attendant's Address |