| Certificate Number | 438 | | Date Issued |
| Child Given Name | Gertrude Maybelle |
Sas | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Sep 1882 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | H.T. |
Sas | Father's Surname |
| Father's Occupation | Loc. Engineer | German | Father's Nationality |
| Father's Birth Place | Michigan | 25 | Father's Age |
| Mother's Given Name | Hattie | Hughes | Mother's Maiden Name |
| Mother's Surname | Sas | Cambridge Story IA | Mother's Residence |
| Mother's Nationality | English | Ohio | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes M.D. | | |