| Certificate Number | 392 | | Date Issued |
| Child Given Name | |
Fruitt | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 29 May 1882 |
Latsobo? IA | Place of Birth |
| Father's Given Name | Chas W. |
Fruitt | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Story Co IA | 26 | Father's Age |
| Mother's Given Name | Sarah E. | Smith | Mother's Maiden Name |
| Mother's Surname | Fruitt | Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 17 | 1 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Squires M.D. | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Squires M.D. | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Squires M.D. | | |