| Certificate Number | 358 | | Date Issued |
| Child Given Name | |
Heffley | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 17 Feb 1882 |
Sherman Twp Story Co iA | Place of Birth |
| Father's Given Name | Robert B. |
Heffley | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 34 | Father's Age |
| Mother's Given Name | Eveline P. | Kelly | Mother's Maiden Name |
| Mother's Surname | Heffley | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |