| Certificate Number | 193 | | Date Issued |
| Child Given Name | Julie J. |
Carpenter | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Jul 1890 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | T. |
Carpenter | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | America | 26 | Father's Age |
| Mother's Given Name | Julia | Wicks | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | G.M. | Roland IA | Medical Attendant's Address |