| Certificate Number | 417 | | Date Issued |
| Child Given Name | |
Allen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 06 Sep 1886 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Ira J. |
Allen | Father's Surname |
| Father's Occupation | Butcher | | Father's Nationality |
| Father's Birth Place | New York | 42 | Father's Age |
| Mother's Given Name | Eliza J. | Blackman | Mother's Maiden Name |
| Mother's Surname | Allen | | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 42 | 8 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | George Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | George Stitzell | | |