| Certificate Number | 180 | | Date Issued |
| Child Given Name | |
Maxwell | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Sep 1885 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | David |
Maxwell | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 42 | Father's Age |
| Mother's Given Name | Jennie | Wakeman | Mother's Maiden Name |
| Mother's Surname | Maxwell | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 5 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |