| Certificate Number | 158 | | Date Issued |
| Child Given Name | Allen M. |
Bates | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 May 1890 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Henry W. |
Bates | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Michigan | 36 | Father's Age |
| Mother's Given Name | Laura | Cassidy | 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 | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Henry W. Bates | Nevada IA | Medical Attendant's Address |