| Certificate Number | 159 | | Date Issued |
| Child Given Name | |
Widner | Child Surname |
| Child Sex | Male |
A | Child Race |
| Date of Birth | 25 Apr 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Edwin P. |
Widner | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 24 | Father's Age |
| Mother's Given Name | Ida M. | Sanford | Mother's Maiden Name |
| Mother's Surname | Widner | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 17 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Boggess | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Boggess | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.W. Boggess | | |