| Certificate Number | 381 | | Date Issued |
| Child Given Name | Effie |
Campbell | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Sep 1886 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Jas |
Campbell | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 28 | Father's Age |
| Mother's Given Name | Sarah | Cousins | Mother's Maiden Name |
| Mother's Surname | Campbell | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |