| Certificate Number | 275 | | Date Issued |
| Child Given Name | |
Nelson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Apr 1886 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | N.J. |
Nelson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 38 | Father's Age |
| Mother's Given Name | Christina | Nelson | Mother's Maiden Name |
| Mother's Surname | Nelson | | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 43 | 7 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |