| Certificate Number | 105 | | Date Issued |
| Child Given Name | Elizabeth Eva |
Diedrich | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Apr 1885 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | John |
Diedrich | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Germany | 34 | Father's Age |
| Mother's Given Name | Hannah | | Mother's Maiden Name |
| Mother's Surname | Dietrich | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Germany | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |