| Certificate Number | 753 | | Date Issued |
| Child Given Name | |
Fish | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Sep 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Thomas Jefferson |
Fish | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 40 | Father's Age |
| Mother's Given Name | Francis E. | Barrett | Mother's Maiden Name |
| Mother's Surname | Fish | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 39 | 5 | Number of Child This Mother |
| Medical Attendant's Name | L.C., Mrs. Butt | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | L.C., Mrs. Butt | Nevada IA | Certificate Signer's Address |
| Returned by Name | L.C., Mrs. Butt | | |