| Certificate Number | 353 | | Date Issued |
| Child Given Name | |
Dolph | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Mar 1889 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Elmer |
Dolph | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 45 | Father's Age |
| Mother's Given Name | | Kennedy | Mother's Maiden Name |
| Mother's Surname | | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 34 | 9 | Number of Child This Mother |
| Medical Attendant's Name | A.P. Edgar | Collins IA | Medical Attendant's Address |