| Certificate Number | 284 | | Date Issued |
| Child Given Name | |
Marsh | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 21 Sep 1881 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Wm Clark |
Marsh | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Poloka IN | 27 | Father's Age |
| Mother's Given Name | Ellen S. | Steiner | Mother's Maiden Name |
| Mother's Surname | Marsh | | Mother's Residence |
| Mother's Nationality | American | Harrison Co IN | Mother's Birth Place |
| Mother's Age | 30 | 3 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrer M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrer M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrer M.D. | | |