| Certificate Number | 134 | | Date Issued |
| Child Given Name | |
Maxwell | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Apr 1890 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | H.I. |
Maxwell | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Iowa | 26 | Father's Age |
| Mother's Given Name | Clara | Gillett | Mother's Maiden Name |
| Mother's Surname | | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 27 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |