| Certificate Number | 169 | | Date Issued |
| Child Given Name | Marietta |
Sellers | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 May 1890 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Geo. B. |
Sellers | Father's Surname |
| Father's Occupation | Machinist | | Father's Nationality |
| Father's Birth Place | Iowa | 24 | Father's Age |
| Mother's Given Name | Angie | Moler | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |