| Certificate Number | 545 | | Date Issued |
| Child Given Name | |
Walbridge | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Geo. E. |
Walbridge | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Michigan | 30 | Father's Age |
| Mother's Given Name | Flora | Belcher | Mother's Maiden Name |
| Mother's Surname | Walbridge | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.E. Scott | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.E. Scott | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.E. Scott | | |