| Certificate Number | 189 | | Date Issued |
| Child Given Name | |
Belcher | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Jan 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | James |
Belcher | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa Center Story Co IA | 31 | Father's Age |
| Mother's Given Name | Mary F. | Linton | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Jeffrey | Nevada IA | Medical Attendant's Address |