| Certificate Number | 108 | | Date Issued |
| Child Given Name | Pearl |
Niebel | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 Mar 1883 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | B.H. |
Neibel | Father's Surname |
| Father's Occupation | Minister | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 30 | Father's Age |
| Mother's Given Name | Lorena | Keller | Mother's Maiden Name |
| Mother's Surname | Neibel | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 31 | 3 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Zearing IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |