| Certificate Number | 394 | | Date Issued |
| Child Given Name | |
Dalley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Dec 1881 |
Nevada | Place of Birth |
| Father's Given Name | Orb |
Dalley | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | Martha | | Mother's Maiden Name |
| Mother's Surname | Dalley | Nevada Story Co IA | Mother's Residence |
| Medical Attendant's Name | Abby M. Penn | | Medical Attendant's Address |
| Certificate Signer's Name | Abbey M. Penn | | Certificate Signer's Address |
| Returned by Name | Abby M. Penn | | |