| Certificate Number | 752 | | Date Issued |
| Child Given Name | Elizabeth |
Stephens | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Sep 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Zimri |
Stephens | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 42 | Father's Age |
| Mother's Given Name | Mary Jane | Quinette | Mother's Maiden Name |
| Mother's Surname | Stephens | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 39 | 5 | Number of Child This Mother |
| Medical Attendant's Name | J. Daughtery | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J. Daughtery | Colo IA | Certificate Signer's Address |
| Returned by Name | J. Daughtery | | |