| Child Given Name | Jessie Ida |
Welty | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 Jun 1886 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Willis Seymour |
Welty | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | West Virginia | 29 | Father's Age |
| Mother's Given Name | Mary Diana | Bonesteel | Mother's Maiden Name |
| Mother's Surname | Welty | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter M.D. | | Medical Attendant's Address |
| Certificate Signer's Name | Mary D. Welty | | Certificate Signer's Address |