| Certificate Number | 191 | | Date Issued |
| Child Given Name | Annie |
Ufford | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 02 Sep 1885 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | A. |
Ufford | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Oneida Co NY | 33 | Father's Age |
| Mother's Given Name | Adel | Clancy | Mother's Maiden Name |
| Mother's Surname | Ufford | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Henry Co IL | Mother's Birth Place |
| Mother's Age | 28 | 5 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Brooks | Zearing | Certificate Signer's Address |
| Returned by Name | A.W. Brooks | | |