| Certificate Number | 89 | | Date Issued |
| Child Given Name | |
Dally | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Mar 1885 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | John |
Dally | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 37 | Father's Age |
| Mother's Given Name | Nancy | Carr | Mother's Maiden Name |
| Mother's Surname | Dally | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 7 | Number of Child This Mother |
| Medical Attendant's Name | John I. Hostetter | | Medical Attendant's Address |
| Certificate Signer's Name | John I. Hostetter | | Certificate Signer's Address |
| Returned by Name | John I. Hostetter | | |