| Certificate Number | 68 | | Date Issued |
| Child Given Name | John |
Kelso | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Jan 1890 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Mountain H. |
Kelso | Father's Surname |
| Father's Occupation | Teacher | | Father's Nationality |
| Father's Birth Place | Oregon | 26 | Father's Age |
| Mother's Given Name | Rosabelle | Erb | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Jane L. Bartlett | Ames IA | Medical Attendant's Address |