| Certificate Number | 180 | | Date Issued |
| Child Given Name | Elsie Frances |
Parks | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Oct 1885 |
| Place of Birth |
| Father's Given Name | Chas. D. |
Parks | Father's Surname |
| Father's Occupation | Printer | | Father's Nationality |
| Father's Birth Place | Illinois | 23 | Father's Age |
| Mother's Given Name | Flora J. | Marvin | Mother's Maiden Name |
| Mother's Surname | Parks | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 26 | 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 | | |