| Certificate Number | 124 | | Date Issued |
| Child Given Name | Clara |
Maxwell | Child Surname |
| Child Sex | |
W | Child Race |
| Date of Birth | 22 Dec 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | G.H. |
Maxwell | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | New York | 39 | Father's Age |
| Mother's Given Name | Elizabeth | Duff | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 31 | | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |