| Certificate Number | 653 | | Date Issued |
| Child Given Name | |
Barickman | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Jun 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Daniel Hl. |
Barickman | Father's Surname |
| Father's Occupation | Saloon Keeper | American | Father's Nationality |
| Father's Birth Place | Illinois | 28 | Father's Age |
| Mother's Given Name | Julia M. | Wilson | Mother's Maiden Name |
| Mother's Surname | Barickman | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 4 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | George Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | George Stitzell | | |