| Certificate Number | 171 | | Date Issued |
| Child Given Name | |
Kirkpatrick | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 09 Apr 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Chas A. |
Kirkpatrick | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Louisa Co IA | 30 | Father's Age |
| Mother's Given Name | Dora G. | Hadley | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Nevada Story Co IA | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlin | Nevada IA | Medical Attendant's Address |