| Certificate Number | 143 | | Date Issued |
| Child Given Name | Lorah Edna |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 May 1888 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | I.N. |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 33 | Father's Age |
| Mother's Given Name | Marilla | Rinehart | Mother's Maiden Name |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |