| Certificate Number | 102 | | Date Issued |
| Child Given Name | |
Fry | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Apr 1885 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo. |
Fry | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 32 | Father's Age |
| Mother's Given Name | Nancy | Chitty | Mother's Maiden Name |
| Mother's Surname | Fry | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 33 | 5 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |