| Certificate Number | 106 | | Date Issued |
| Child Given Name | Leland |
Bates | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 30 Nov 1880 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Elnathan |
Bates | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Williams Co OH | 27 | Father's Age |
| Mother's Given Name | Margaret | Miller | Mother's Maiden Name |
| Mother's Surname | Bates | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Defiance Co OH | Mother's Birth Place |
| Mother's Age | 29 | 5 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |