| Certificate Number | 52 | | Date Issued |
| Child Given Name | Addie Lafloba |
Millhouse | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Jul 1880 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Jacob |
Millhouse | Father's Surname |
| Father's Occupation | Farmer & Stockman | American | Father's Nationality |
| Father's Birth Place | Indiana | 30 | Father's Age |
| Mother's Given Name | Annie | Jones | Mother's Maiden Name |
| Mother's Surname | Millhouse | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 21 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Milton W. Ritchey | Jasper Co IA | Medical Attendant's Address |
| Certificate Signer's Name | Milton W. Ritchey | Clyde Jasper Co IA | Certificate Signer's Address |
| Returned by Name | 'mail' | | |