| Certificate Number | 720 | | Date Issued |
| Child Given Name | |
Adams | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Aug 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Henry |
Adams | Father's Surname |
| Father's Occupation | Brick layer | American | Father's Nationality |
| Father's Birth Place | I? | 29 | Father's Age |
| Mother's Given Name | Ella | Benjamin | Mother's Maiden Name |
| Mother's Surname | Adams | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Mass | Mother's Birth Place |
| Mother's Age | 26 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |