| Certificate Number | 206 | | Date Issued |
| Child Given Name | James M. |
Kelly | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Jun 1889 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | George |
Kelly | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 27 | Father's Age |
| Mother's Given Name | Leodena | McCallister | Mother's Maiden Name |
| Mother's Surname | | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 36 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |