| Certificate Number | 49 | | Date Issued |
| Child Given Name | Effa Alice |
Whitehead | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Aug 1880 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Melvel B. |
Whitehead | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 32 | Father's Age |
| Mother's Given Name | Nancy D. | Besett | Mother's Maiden Name |
| Mother's Surname | Whitehead | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | A.P. Edgar | Clyde Jasper Co IA | Medical Attendant's Address |
| Certificate Signer's Name | A.P. Edgar | Clyde Jasper Co IA | Certificate Signer's Address |
| Returned by Name | 'mail' | | |