| Certificate Number | 1049 | | Date Issued |
| Child Given Name | Sarah Edna |
Rice | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 30 Aug 1884 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Edwin R. |
Rice | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 34 | Father's Age |
| Mother's Given Name | Lizzie | France | Mother's Maiden Name |
| Mother's Surname | Rice | | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo. Stitzell | | |