| Certificate Number | 195 | | Date Issued |
| Child Given Name | Adella Mae |
Keltner | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Jul 1890 |
Washington Twp 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 | 51 | Father's Age |
| Mother's Given Name | Emily | Wiltse | Mother's Maiden Name |
| Mother's Surname | Keltner | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 46 | 11 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fandula | Ames IA | Medical Attendant's Address |