| Certificate Number | 213 | | Date Issued |
| Child Given Name | |
Belt | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 22 Jul 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | L.A. |
Belt | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Black Hawk Co IA | 22 | Father's Age |
| Mother's Given Name | M.E., Mrs. | Leach | Mother's Maiden Name |
| Mother's Surname | Belt | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Buchanan Co IA | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |