| Certificate Number | 369 | | Date Issued |
| Child Given Name | Amy |
Lapp | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 21 Feb 1882 |
Gilbert Station Story Co IA | Place of Birth |
| Father's Given Name | Jacob |
Lapp | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 38 | Father's Age |
| Mother's Given Name | Amy | Alvard | Mother's Maiden Name |
| Mother's Surname | Lapp | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | 35 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Rachael Marshall | Gilbert Station IA | Medical Attendant's Address |
| Certificate Signer's Name | Rachael Marshall | Gilbert Station IA | Certificate Signer's Address |
| Returned by Name | R. Marshall | | |