| Certificate Number | 739 | | Date Issued |
| Child Given Name | Nellie |
Nelson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Aug 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Jacob |
Nelson | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 32 | Father's Age |
| Mother's Given Name | Mary | Nelson | Mother's Maiden Name |
| Mother's Surname | Nelson | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 31 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |