| Certificate Number | 1024 | | Date Issued |
| Child Given Name | Alice |
Young | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Sep 1884 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | George M. |
Young | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 28 | Father's Age |
| Mother's Given Name | Sara | Chamness | Mother's Maiden Name |
| Mother's Surname | Young | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Missouri | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |