| Certificate Number | 994 | | Date Issued |
| Child Given Name | |
Rubar | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 May 1884 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Charles |
Rubar | Father's Surname |
| Father's Occupation | Jeweler | American | Father's Nationality |
| Father's Birth Place | Iowa | 23 | Father's Age |
| Mother's Given Name | Lydia | Howell | Mother's Maiden Name |
| Mother's Surname | Rubar | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 15 | 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 | | |