| Certificate Number | 820 | | Date Issued |
| Child Given Name | Annie Grace |
Frey | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Sep 1882 |
| Place of Birth |
| Father's Given Name | Benard |
Frey | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 41 | Father's Age |
| Mother's Given Name | Mary | Wiser | Mother's Maiden Name |
| Mother's Surname | Frey | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 37 | 7 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |