| Certificate Number | 1005 | | Date Issued |
| Child Given Name | Elmer Nicholas |
Kersey | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Jul 1884 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Simon |
Kersey | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Clinton Co OH | 34 | Father's Age |
| Mother's Given Name | Ida A. | Ufford | Mother's Maiden Name |
| Mother's Surname | Kersey | | Mother's Residence |
| Mother's Nationality | American | Marshall Co IA | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.S., Dr. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | J.S., Dr. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | J.S., Dr. Newton | | |