| Certificate Number | 287 | | Date Issued |
| Child Given Name | Alice |
O'Donnell | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Jul 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Jerry |
O'Donnell | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Indiana | 29 | Father's Age |
| Mother's Given Name | Anna | Collins | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Tennessee | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |