| Certificate Number | 233 | | Date Issued |
| Child Given Name | |
Bell | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 05 Aug 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | E. Frank |
Bell | Father's Surname |
| Father's Occupation | Educator | | Father's Nationality |
| Mother's Given Name | C. | Michaelson | Mother's Maiden Name |
| Mother's Surname | Bell | Nevada Story Co IA | Mother's Residence |
| Mother's Age | | 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 | | |