| Certificate Number | 1001 | | Date Issued |
| Child Given Name | Clarence W. |
Southwick | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 23 Jul 1884 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Albert W. |
Southwick | Father's Surname |
| Father's Occupation | P.M. | American | Father's Nationality |
| Father's Birth Place | New York | 28 | Father's Age |
| Mother's Given Name | Irene M. | Spar | Mother's Maiden Name |
| Mother's Surname | Southwick | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |