| Certificate Number | 269 | | Date Issued |
| Child Given Name | Charley Emerson |
Kelly | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 24 Nov 1881 |
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 | 23 | Father's Age |
| Mother's Given Name | Martha | Lawman | Mother's Maiden Name |
| Mother's Surname | Kelley | | Mother's Residence |
| Mother's Nationality | Canadian | | Mother's Birth Place |
| Mother's Age | 19 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler | Nevada IA | Certificate Signer's Address |
| Returned by Name | Lewis Schooler | | |