| Certificate Number | 127 | | Date Issued |
| Child Given Name | Charles Everett |
Alexander | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Jun 1885 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Thomas |
Alexander | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Ohio | 24 | Father's Age |
| Mother's Given Name | Lucy | Graham | Mother's Maiden Name |
| Mother's Surname | Alexander | Michigan | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 24 | 4 | 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 | | |