| Certificate Number | 106 | | Date Issued |
| Child Given Name | |
Alma | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Mar 1888 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | J.W. |
Alma | Father's Surname |
| Father's Occupation | Poultryman | | Father's Nationality |
| Father's Birth Place | Ohio | 27 | Father's Age |
| Mother's Given Name | Ida W. | Wooley | Mother's Maiden Name |
| Mother's Surname | Alma | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlain | Nevada IA | Medical Attendant's Address |