| Certificate Number | 947 | | Date Issued |
| Child Given Name | |
Fisher | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Apr 884 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Levi |
Fisher | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Indiana | 39 | Father's Age |
| Mother's Given Name | B.S. | Smith | Mother's Maiden Name |
| Mother's Surname | Fisher | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 37 | 7 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |