| Certificate Number | 56 | | Date Issued |
| Child Given Name | |
Kirkendall | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Jan 1888 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | James |
Kirkendall | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 41 | Father's Age |
| Mother's Given Name | C.A. | Halley | Mother's Maiden Name |
| Mother's Surname | Kirkendall | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 39 | 5 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |