| Certificate Number | 622 | | Date Issued |
| Child Given Name | Olive Ethel |
Dickinson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 06 Apr 1883 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | Jonas I. |
Dick | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Iowa | 40 | Father's Age |
| Mother's Given Name | Martha | Spicer | Mother's Maiden Name |
| Mother's Surname | Dickinson | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 39 | 7 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell Ia | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Maxwell Story Co IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |