| Certificate Number | 511 | | Date Issued |
| Child Given Name | |
Storm | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Dec 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | J. William |
Storm | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 33 | Father's Age |
| Mother's Given Name | Emma A. | Mason | Mother's Maiden Name |
| Mother's Surname | Storm | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 33 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler | Nevada IA | Certificate Signer's Address |
| Returned by Name | Lewis Schooler | | |