| Certificate Number | 304 | | Date Issued |
| Child Given Name | Effie Josephine |
Lee | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Sep 1889 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Jacob |
Lee | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 34 | Father's Age |
| Mother's Given Name | Cordelia | Macy | Mother's Maiden Name |
| Mother's Surname | | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 29 | 7 | Number of Child This Mother |
| Medical Attendant's Name | A.S. Aplin | Cambridge IA | Medical Attendant's Address |