| Certificate Number | 682 | | Date Issued |
| Child Given Name | John Melvin |
Ulch | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Simon Peter |
Ulch | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | | 37 | Father's Age |
| Mother's Given Name | Sarah Ann | Strachen | Mother's Maiden Name |
| Mother's Surname | Ulch | Story Co IA | Mother's Residence |
| Mother's Age | 33 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Abbey M. Penn | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Abbey M. Penn | Nevada IA | Certificate Signer's Address |
| Returned by Name | Abbey M. Penn | | |