| Certificate Number | 283 | | Date Issued |
| Child Given Name | Ella Josephine |
Sime | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 01 Nov 1881 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Thomas |
Sime | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | Fanny Jane | Patrick | Mother's Maiden Name |
| Mother's Surname | Sime | | Mother's Residence |
| Mother's Age | | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Monk M.D. | | |