| Certificate Number | 266 | | Date Issued |
| Child Given Name | Flossie M. |
Fish | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Jul 1889 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | J.F. |
Fish | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 27 | Father's Age |
| Mother's Given Name | Flora | Gearhart | Mother's Maiden Name |
| Mother's Surname | Fish | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |