| Certificate Number | 74 | | Date Issued |
| Child Given Name | Chester A. |
Dickman | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Nov 1889 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Jas. W. |
Dickinson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 27 | Father's Age |
| Mother's Given Name | Allie | Gearhart | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Colo Story Co IA | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |