| Certificate Number | 330 | | Date Issued |
| Child Given Name | Herbert Lee |
White | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 16 Dec 1885 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Joseph |
White | Father's Surname |
| Father's Birth Place | Indiana | 31 | Father's Age |
| Mother's Given Name | Mary E. | Taylor | Mother's Maiden Name |
| Mother's Surname | White | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |