| Certificate Number | 15 | | Date Issued |
| Child Given Name | Jadwell E. |
Nichols | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Oct 1889 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Foster |
Nichols | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Oskaloosa IA | 20 | Father's Age |
| Mother's Given Name | Minnie | Erickson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Anna G. Torkheim | Story City IA | Medical Attendant's Address |