| Certificate Number | 92 | | Date Issued |
| Child Given Name | Lillie Dale |
Scott | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Feb 1885 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | C.W. |
Scott | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Mary C. | Fosha | Mother's Maiden Name |
| Mother's Surname | Scott | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 21 | 2 | Number of Child This Mother |
| Medical Attendant's Name | S., Mrs. Martin | | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | | Certificate Signer's Address |