| Certificate Number | 818 | | Date Issued |
| Child Given Name | |
Roorch | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Nov 1883 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | H.C. |
Rooch | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 33 | Father's Age |
| Mother's Given Name | M.J. | Dawson | Mother's Maiden Name |
| Mother's Surname | Roorch | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |