| Certificate Number | 520 | | Date Issued |
| Child Given Name | Ruth |
Ballou | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Mar 1887 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | V.A. |
Ballou | Father's Surname |
| Father's Occupation | Printer | | Father's Nationality |
| Father's Birth Place | New York | 47 | Father's Age |
| Mother's Given Name | A. | Mullen | Mother's Maiden Name |
| Mother's Surname | Ballou | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 44 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |