| Decedent's Given Name | |
Day | Decedent's Surname |
| Location | Collins Twp |
212 | Enumeration District |
| Enumerator | William V. Dawes |
105 | Family Number |
| Age | 1/30 |
F | Sex |
| Color | W |
Single | Marital Status |
| Birth Place | Iowa |
Indiana | Father's Birth Place |
| Mother's Birth Place | Illinois |
| Occupation |
| Month of Death | Feb |
| Cause of Death |
| How long in Story Co. | 1/30 |
| Where illness contracted |
| Attending Physician | none |
| Physician's Statement - Primary Cause |
| Physician's Statement - Immediate Cause | |
| Physician's Signature |
| Enumerator Remarks: | |
The following is not taken from the schedule. See the introduction for an explanation of sources.
| Birth Date | Feb 1880 |
Feb 1880 | Death Date |
| Head of Household Given Name | Jerome |
Day | Head of Household Surname |
| Grave Marker in Story Co.? | No |
| Cemetery |
| Grave Marker Information: | |
| Transcriber Comments: | |