| Certificate Number | 803 | | Date Issued |
| Child Given Name | |
Farrar | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 13 Nov 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Preston W. |
Farrar | Father's Surname |
| Father's Occupation | Physician | American | Father's Nationality |
| Father's Birth Place | Washington Co PA | 39 | Father's Age |
| Mother's Given Name | Jane | Dillon | Mother's Maiden Name |
| Mother's Surname | Farrar | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 28 | 6 | 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 | | |