| Certificate Number | 278 | | Date Issued |
| Child Given Name | |
Heef | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 18 Dec 1881 |
| Place of Birth |
| Father's Given Name | Danl |
Heef | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Hamilton Co IA | 24 | Father's Age |
| Mother's Given Name | Viola | Webb | Mother's Maiden Name |
| Mother's Nationality | American | Polk Co IA | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.R. Myers | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | J.R. Myers | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | J.R. Myers | | |