| Certificate Number | 122 | | Date Issued |
| Child Given Name | Ica Ocle |
Carver | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 Feb 1889 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | E.B. |
Carver | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 45 | Father's Age |
| Mother's Given Name | Retta | Lindsay | Mother's Maiden Name |
| Mother's Surname | | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 45 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |