| Certificate Number | 230 | | Date Issued |
| Child Given Name | |
Keltner | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 Dec 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Henry |
Keltner | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 46 | Father's Age |
| Mother's Given Name | Emily | Wiltsie | Mother's Maiden Name |
| Mother's Surname | Keltner | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 40 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | E.B. Plumb | Ames IA | Certificate Signer's Address |
| Returned by Name | E.B. Plumb | | |