| Certificate Number | 55 | | Date Issued |
| Child Given Name | Jno. Wm |
Kelley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Nathan |
Kelley | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Story Co IA | 22 | Father's Age |
| Mother's Given Name | Martha | Lawman | Mother's Maiden Name |
| Mother's Surname | Kelly | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Boggess | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Boggess | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.W. Boggess | | |