| Certificate Number | 198 | | Date Issued |
| Child Given Name | Frank Thomas |
Kelly | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Jul 1888 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Nathan |
Kelly | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 29 | Father's Age |
| Mother's Given Name | Martha | Lawman | Mother's Maiden Name |
| Mother's Surname | | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 36 | | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlin | Nevada IA | Medical Attendant's Address |