| Certificate Number | 4 | | Date Issued |
| Child Given Name | Maggie May |
Griffith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Jul 1880 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Asa B. |
Griffith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | Julia Ann | Thomas | Mother's Maiden Name |
| Mother's Surname | Griffith | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Carrol Co IN | Mother's Birth Place |
| Mother's Age | 40 | 9 | Number of Child This Mother |
| Medical Attendant's Name | E. Henn Monk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Margaret M. Shickles | | Certificate Signer's Address |
| Returned by Name | E.Henn Monk | | |