| Certificate Number | 90 | | Date Issued |
| Child Given Name | |
Dickinson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Feb 1890 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Dorphis |
Dickinson | Father's Surname |
| Father's Occupation | Barber | | Father's Nationality |
| Father's Birth Place | Clinton IA | 34 | Father's Age |
| Mother's Given Name | Hattie | Johnson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 28 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Peterson | Story City IA | Medical Attendant's Address |