| Certificate Number | 212 | | Date Issued |
| Child Given Name | |
Fry | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Aug 1890 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Jas A. |
Fry | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Iowa | 36 | Father's Age |
| Mother's Given Name | Millie | Owen | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Jeffrey | Nevada IA | Medical Attendant's Address |