| Certificate Number | 202 | | Date Issued |
| Child Given Name | |
Roarch | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Nov 1885 |
| Place of Birth |
| Father's Given Name | Hank C. |
Roarch | Father's Surname |
| Father's Occupation | Produce Dealer | | Father's Nationality |
| Father's Birth Place | Indiana | 36 | Father's Age |
| Mother's Given Name | Jennie | Dawson | Mother's Maiden Name |
| Mother's Surname | Roarch | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 25 | 3 | 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 | | |