| Certificate Number | 131 | | Date Issued |
| Child Given Name | Electra |
Sage | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Feb 1881 |
| Place of Birth |
| Father's Given Name | Emerson Wesley |
Sage | Father's Surname |
| Father's Occupation | Minister | Canadian | Father's Nationality |
| Father's Birth Place | Oxford Co Canada | 37 | Father's Age |
| Mother's Given Name | Rhoda Josephine | Jenkins | Mother's Maiden Name |
| Mother's Surname | Sage | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 33 | 4 | Number of Child This Mother |
| Medical Attendant's Name | L.C. Butt | | Medical Attendant's Address |
| Certificate Signer's Name | L.C. Butt | | Certificate Signer's Address |
| Returned by Name | L.C. Butt | | |