| Certificate Number | 1004 | | Date Issued |
| Child Given Name | |
Fry | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 31 Jul 1884 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | John E. |
Fry | Father's Surname |
| Father's Occupation | Blacksmith | American | Father's Nationality |
| Father's Birth Place | Indiana | 42 | Father's Age |
| Mother's Given Name | Elizabeth | Belcher | Mother's Maiden Name |
| Mother's Surname | Fry | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 33 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Frank Thompson | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Frank Thompson | | |