| Certificate Number | 842 | | Date Issued |
| Child Given Name | |
Maxwell | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Dec 1883 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Harry I. |
Maxwell | Father's Surname |
| Father's Occupation | Merchant | American | Father's Nationality |
| Father's Birth Place | Story Co IA | 21 | Father's Age |
| Mother's Given Name | Clara | Gillett | Mother's Maiden Name |
| Mother's Surname | Maxwell | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 21 | 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. | | |