| Certificate Number | 789 | | Date Issued |
| Child Given Name | Dorr Ira |
Allen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Oct 1883 |
Nevada IA Story Co IA | Place of Birth |
| Father's Given Name | Ira J. |
Allen | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | New York | 39 | Father's Age |
| Mother's Given Name | Eliza J. | Blackman | Mother's Maiden Name |
| Mother's Surname | Allen | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 29 | 9 | Number of Child This Mother |
| Certificate Signer's Name | Geo. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo. Stitzell | | |