| Certificate Number | 180 | | Date Issued |
| Child Given Name | |
Posegate | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 30 Apr 1881 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Eli F. |
Posegate | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Iowa | | Father's Age |
| Mother's Given Name | Frances A. | McKeen | Mother's Maiden Name |
| Mother's Surname | Posegate | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | | 2 | 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 | | |