| Certificate Number | 254 | | Date Issued |
| Child Given Name | Charles Willson |
Fisher | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Oct 1881 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Orison C. |
Fish | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 34 | Father's Age |
| Mother's Given Name | Lucia A. | Salvare | Mother's Maiden Name |
| Mother's Surname | Fish | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | | 4 | Number of Child This Mother |
| Medical Attendant's Name | A.P. Edgars | Clyde IA | Medical Attendant's Address |
| Certificate Signer's Name | A.P. Edgars | Clyde IA | Certificate Signer's Address |
| Returned by Name | A.P. Edgars | | |