| Certificate Number | 138 | | Date Issued |
| Child Given Name | Bertha Frances |
Loucks | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 May 1890 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | E. |
Loucks | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Virginia | 43 | Father's Age |
| Mother's Given Name | Polly A. | Parker | Mother's Maiden Name |
| Mother's Surname | | Kansas | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 43 | 12 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlain | Nevada IA | Medical Attendant's Address |