| Certificate Number | 621 | | Date Issued |
| Child Given Name | Maude Marie |
King | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Sep 1887 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | M.F. |
King | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Iowa | | Father's Age |
| Mother's Given Name | Ruth | Clawson | Mother's Maiden Name |
| Mother's Surname | King | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |