| Certificate Number | 915 | | Date Issued |
| Child Given Name | Rosa Ann |
Stoll | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Apr 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | T.W.J.C. |
Stoll | Father's Surname |
| Father's Occupation | Car Repairer | German | Father's Nationality |
| Father's Birth Place | Germany | 29 | Father's Age |
| Mother's Given Name | Creston Sophia | Jensen | Mother's Maiden Name |
| Mother's Surname | Stoll | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | German | Germany | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.L. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L. Bartlett | | |