| Certificate Number | 113 | | Date Issued |
| Child Given Name | Dora Dale |
Dickinson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Jan 1881 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Jas K. |
Dickinson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 27 | Father's Age |
| Mother's Given Name | Loretta | King | Mother's Maiden Name |
| Mother's Surname | Dickinson | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Frazee | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Frazee | Colo IA | Certificate Signer's Address |
| Returned by Name | Geo. Frazee | | |