| Certificate Number | 81 | | Date Issued |
| Child Given Name | Ora Mae |
Wicks | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Nov 1888 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Nels |
Wicks | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Norway | 29 | Father's Age |
| Mother's Given Name | Caroline | Knudson | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 24 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Martine Birkland | Roland IA | Medical Attendant's Address |