| Certificate Number | 561 | | Date Issued |
| Child Given Name | |
Allen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Dec 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | L.E. |
Allen | Father's Surname |
| Father's Occupation | Painter | American | Father's Nationality |
| Father's Birth Place | New York | 34 | Father's Age |
| Mother's Given Name | Elizabeth | Hendrickson | Mother's Maiden Name |
| Mother's Surname | Allen | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 3 | 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 | | |