| Certificate Number | 444 | | Date Issued |
| Child Given Name | |
Shafer | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 31 Aug 1882 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | James E. |
Shafer | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 27 | Father's Age |
| Mother's Given Name | Lida | Field | Mother's Maiden Name |
| Mother's Surname | Shafer | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Irish | Ireland | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes M.D. | | |