| Certificate Number | 804 | | Date Issued |
| Child Given Name | John Archibald |
Nelson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Nov 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Wm. H. |
Nelson | Father's Surname |
| Father's Occupation | Real Estate | American | Father's Nationality |
| Father's Birth Place | Bloomfield OH | 27 | Father's Age |
| Mother's Given Name | Libble S. | McFarlane | Mother's Maiden Name |
| Mother's Surname | Nelson | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Schenectady NY | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |