| Certificate Number | 108 | | Date Issued |
| Child Given Name | Claire Josephine |
Flack | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Jan 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Frank A. |
Flack | Father's Surname |
| Father's Occupation | Barber | | Father's Nationality |
| Father's Birth Place | Illinois | 29 | Father's Age |
| Mother's Given Name | Carrie | Statler | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 21 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |