| Certificate Number | 656 | | Date Issued |
| Child Given Name | |
Bachlet | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 May 1883 |
Nevada Ia | Place of Birth |
| Father's Given Name | H.J. |
Bachlet | Father's Surname |
| Father's Occupation | Carpenter | American | Father's Nationality |
| Father's Birth Place | Ohio | 37 | Father's Age |
| Mother's Given Name | Bertha | McDowell | Mother's Maiden Name |
| Mother's Surname | Bachlet | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 30 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |