| Certificate Number | 96 | | Date Issued |
| Child Given Name | |
Lee | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Mar 1885 |
| Place of Birth |
| Father's Given Name | J. |
Lee | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 36 | Father's Age |
| Mother's Given Name | Sarah J. | Pierce | Mother's Maiden Name |
| Mother's Surname | Lee | Ballard Grove Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 32 | 6 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |