| Certificate Number | 378 | | Date Issued |
| Child Given Name | |
Kinsell | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Sep 1886 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | J.W. |
Kinsell | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 40 | Father's Age |
| Mother's Given Name | Euphenia L. | Hall | Mother's Maiden Name |
| Mother's Surname | Kinsell | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 35 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Hall | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | L.E., Mrs. Butt | | Certificate Signer's Address |