| Certificate Number | 263 | | Date Issued |
| Child Given Name | Alta |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 13 Jul 1885 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | F.S. |
Smith | Father's Surname |
| Father's Occupation | M.D. | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 32 | Father's Age |
| Mother's Given Name | Ella W. | Wells | Mother's Maiden Name |
| Mother's Surname | Smith | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 2 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Smith | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Smith | Nevada IA | Certificate Signer's Address |
| Returned by Name | F.S. Smith | | |