| Certificate Number | 904 | | Date Issued |
| Child Given Name | Ella Amelia |
Weeks | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Dec 1883 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Wier |
Weeks | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 43 | Father's Age |
| Mother's Given Name | Randy | Sheldahl | Mother's Maiden Name |
| Mother's Surname | Weeks | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 33 | 7 | 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 | | |