| Certificate Number | 705 | | Date Issued |
| Child Given Name | Ira Ellworth |
Fisher | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Jul 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Nathan Truman |
Fisher | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Ohio | 29 | Father's Age |
| Mother's Given Name | Sabra J. | Johnson | Mother's Maiden Name |
| Mother's Surname | Fisher | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Abbey M. Penn | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Abbey M. Penn | Nevada IA | Certificate Signer's Address |
| Returned by Name | Abbey M. Penn | | |