| Certificate Number | 659 | | Date Issued |
| Child Given Name | Ethel M. |
Shelton | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 May 1883 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Wm W. |
Shelton | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 29 | Father's Age |
| Mother's Given Name | Ester Ann | Roark | Mother's Maiden Name |
| Mother's Surname | Shelton | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo. Stitzell | | |