| Certificate Number | 377 | | Date Issued |
| Child Given Name | Alice Marie |
Nelsen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 May 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Wm. H. |
Nelson | Father's Surname |
| Father's Occupation | Ab?nect and Ins Agt | American | Father's Nationality |
| Father's Birth Place | Ohio | 25 | Father's Age |
| Mother's Given Name | Libbie S. | McFarlan | Mother's Maiden Name |
| Mother's Surname | Nelson | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 25 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar M.D. | | |