| Certificate Number | 18 | | Date Issued |
| Child Given Name | Sarah J. |
Ericson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Sep 1889 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | E.L. |
Ericson | Father's Surname |
| Father's Occupation | Teacher | | Father's Nationality |
| Father's Birth Place | Lisbon IL | 29 | Father's Age |
| Mother's Given Name | G.A. | Larson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Story City Story Co IA | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J. Emmett | Story City IA | Medical Attendant's Address |