| Certificate Number | 68 | | Date Issued |
| Child Given Name | |
Ballard | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Oct 1880 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Henry D. |
Ballard | Father's Surname |
| Father's Occupation | Bookkeeper & Salesman | American | Father's Nationality |
| Father's Birth Place | Allegheny Co NY | 37 | Father's Age |
| Mother's Given Name | Emerette | Nash | Mother's Maiden Name |
| Mother's Surname | Ballard | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Madison Co NY | Mother's Birth Place |
| Mother's Age | 33 | 5 | 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 | | |