| Certificate Number | 737 | | Date Issued |
| Child Given Name | Edna Clementine |
Banks | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Sep 1883 |
Story County IA | Place of Birth |
| Father's Given Name | Charles L. |
Banks | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 23 | Father's Age |
| Mother's Given Name | Mary Ellen | Knight | Mother's Maiden Name |
| Mother's Surname | Banks | Story County IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 17 | 1 | 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 | | |