| Certificate Number | 258 | | Date Issued |
| Child Given Name | Daisy Sarah |
Kitchen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Aug 1889 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | Andrew |
Kitchen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 35 | Father's Age |
| Mother's Given Name | Lizzie | Smith | Mother's Maiden Name |
| Mother's Surname | | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F. Thompson | Iowa Center IA | Medical Attendant's Address |