| Certificate Number | 4 | | Date Issued |
| Child Given Name | Thomas G. |
Fultz | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Oct 1887 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Thos D. |
Fultz | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Missouri | 26 | Father's Age |
| Mother's Given Name | Julia | Maxwell | Mother's Maiden Name |
| Mother's Surname | Fultz | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |