| Certificate Number | 135 | | Date Issued |
| Child Given Name | |
Fisher | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Oct 1884 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Elijah |
Fisher | Father's Surname |
| Father's Occupation | Ditcher | American | Father's Nationality |
| Father's Birth Place | Indiana | 26 | Father's Age |
| Mother's Given Name | Clara | Buffington | Mother's Maiden Name |
| Mother's Surname | Fisher | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.A. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.A. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.A. Munk | | |