| Certificate Number | 148 | | Date Issued |
| Child Given Name | Silva |
Nellis | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 27 Mar 1881 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Charles |
Nellis | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Newbremom Co NY | 30 | Father's Age |
| Mother's Given Name | Alis E. | Chandler | Mother's Maiden Name |
| Mother's Surname | Nellis | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Cambridge IA | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |