| Certificate Number | 944 | | Date Issued |
| Child Given Name | Florence M. |
Maxwell | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 May 1884 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Sidney I. |
Maxwell | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 22 | Father's Age |
| Mother's Given Name | Lizzie A. | Hall | Mother's Maiden Name |
| Mother's Surname | Maxwell | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 21 | 1 | 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 | | |