| Certificate Number | 775 | | Date Issued |
| Child Given Name | |
Kelly | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Oct 1881 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Carmody? |
Kelly | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 32 | Father's Age |
| Mother's Given Name | | French | Mother's Maiden Name |
| Mother's Surname | Kelly | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wisconson | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |