| Certificate Number | 245 | | Date Issued |
| Child Given Name | William Garfield |
Nelson | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 27 Sep 1881 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Jno D. |
Nelson | Father's Surname |
| Father's Occupation | Farmer | Dane | Father's Nationality |
| Father's Birth Place | Denmark | 41 | Father's Age |
| Mother's Given Name | Racheal | Reasoner | Mother's Maiden Name |
| Mother's Surname | Nelson | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | 25 | 5 | Number of Child This Mother |
| Medical Attendant's Name | P.H. Sharp | Kelly IA | Medical Attendant's Address |
| Certificate Signer's Name | P.H. Sharp | Kelly IA | Certificate Signer's Address |
| Returned by Name | P.H. Sharp | | |