| Certificate Number | 87 | | Date Issued |
| Child Given Name | |
Dikinson | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 19 Oct 1880 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Geo |
Dickenson | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | New York | 45 | Father's Age |
| Mother's Given Name | Nancy | Vincent | Mother's Maiden Name |
| Mother's Surname | Dikinson | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 34 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo P. Johnston | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo P. Johnson | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Geo P. Johnson | | |