| Certificate Number | 3 | | Date Issued |
| Child Given Name | George R. |
Maynard | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Jul 1880 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Wm Wallace |
Maynard | Father's Surname |
| Father's Occupation | Brick Manf | | Father's Nationality |
| Father's Birth Place | Canada | 21 | Father's Age |
| Mother's Given Name | Emma Jane | Robinson | Mother's Maiden Name |
| Mother's Surname | Maynard | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Nevada Story Co IA | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.S. Torrell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.S. Torrell | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.S. Torrell | | |