| Certificate Number | 600 | | Date Issued |
| Child Given Name | |
Wire | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Mar 1883 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Gid Jay |
Wire | Father's Surname |
| Father's Occupation | Carpenter | American | Father's Nationality |
| Father's Birth Place | Ohio | 44 | Father's Age |
| Mother's Given Name | Allie | Southwick | Mother's Maiden Name |
| Mother's Surname | Wire | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 35 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Southwick | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | Mrs. Southwick | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |