| Certificate Number | 876 | | Date Issued |
| Child Given Name | |
Norris | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Jan 1884 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | C.V. |
Norris | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 23 | Father's Age |
| Mother's Given Name | Anna | Eccles | Mother's Maiden Name |
| Mother's Surname | Norris | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |