| Certificate Number | 918 | | Date Issued |
| Child Given Name | |
Kelly | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Mar 1884 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo W. |
Kelly | Father's Surname |
| Father's Occupation | | American | Father's Nationality |
| Father's Birth Place | Indiana | 50 | Father's Age |
| Mother's Given Name | Henrietta | Selby | Mother's Maiden Name |
| Mother's Surname | Kelly | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 42 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.L. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L. Bartlett | | |