| Certificate Number | 684 | | Date Issued |
| Child Given Name | Lulu Belle |
Sutherland | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Jun 1883 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | David E. |
Sutherland | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | Ann Rebecca | Cork | Mother's Maiden Name |
| Mother's Surname | Sutherland | Grant Twp Story Co IA | Mother's Residence |
| Mother's Age | 34 | 7 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |