| Certificate Number | 74 | | Date Issued |
| Child Given Name | Arthur Selas |
Smith | Child Surname |
| Child Sex | Male |
A | Child Race |
| Date of Birth | 29 Nov 1880 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Henry Selah |
Smith | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 46 | Father's Age |
| Mother's Given Name | Mary Elizabeth | Carendish | Mother's Maiden Name |
| Mother's Surname | Smith | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 35 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Rachel Marshall | Gilbert Station IA | Medical Attendant's Address |
| Certificate Signer's Name | Rachel Marshall | Gilbert Station IA | Certificate Signer's Address |
| Returned by Name | Rachel Marshall | | |