| Certificate Number | 367 | | Date Issued |
| Child Given Name | Agnes Mary |
Lehman | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 02 Aug 1886 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Robert |
Lehman | Father's Surname |
| Father's Occupation | Section Boss | | Father's Nationality |
| Father's Birth Place | Prussia | 29 | Father's Age |
| Mother's Given Name | Ollie M. | Hughes | Mother's Maiden Name |
| Mother's Surname | Lehman | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Benton Co IA | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown M.D. | | |