| Certificate Number | 337 | | Date Issued |
| Child Given Name | Elsie |
Lacy | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 May 1886 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Patrick |
Lacy | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Canada | 40 | Father's Age |
| Mother's Given Name | Matilda | Mchone | Mother's Maiden Name |
| Mother's Surname | Lacy | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 29 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |