| Certificate Number | 166 | | Date Issued |
| Child Given Name | Addie Victora |
Cook | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 25 Apr 1881 |
| Place of Birth |
| Father's Given Name | Cas. |
Cook | Father's Surname |
| Father's Occupation | Harness Maker | American | Father's Nationality |
| Mother's Given Name | Henrietta | Water | Mother's Maiden Name |
| Mother's Nationality | American | | Mother's Birth Place |
| Mother's Age | | 14 | Number of Child This Mother |
| Medical Attendant's Name | P.H., Mrs. & Mrs. Sharp | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | P.H., Mr. & Mrs. Sharp | Cambridge IA | Certificate Signer's Address |
| Returned by Name | P.H., Mr. & Mrs. Sharp | | |