| Certificate Number | 148 | | Date Issued |
| Child Given Name | |
Dick | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Jun 1888 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Jonas |
Dick | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Ohio | 46 | Father's Age |
| Mother's Given Name | Martha | Spicer | Mother's Maiden Name |
| Mother's Surname | Dick | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 39 | 9 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell Ia | Medical Attendant's Address |