| Certificate Number | 554 | | Date Issued |
| Child Given Name | |
Mason | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Jan 1883 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | William Ross |
Mason | Father's Surname |
| Father's Occupation | Trader in stock | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 36 | Father's Age |
| Mother's Given Name | Emma R. | Mathews | Mother's Maiden Name |
| Mother's Surname | Mason | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 28 | 4 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |