| Certificate Number | 549 | | Date Issued |
| Child Given Name | Perry Edgar |
Vanhorn | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Jan 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Frank M. |
Vanhorn | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | | 28 | Father's Age |
| Mother's Given Name | Addie M. | Hadley | Mother's Maiden Name |
| Mother's Surname | Vanhorn | Nevada Story Co IA | Mother's Residence |
| 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 | | |