| Certificate Number | 65 | | Date Issued |
| Child Given Name | Bessie |
Kelley | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Feb 1884 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Nathan |
Kelley | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 26 | Father's Age |
| Mother's Given Name | Martha | Lawman | Mother's Maiden Name |
| Mother's Surname | Kelley | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 21 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.E. Scott | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.E. Scott | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.E. Scott | | |