Transcription from photocopy of original record:
"Report of Birth
Vital Statistics Department - County Clerk's Office
Cook County, State of Illinois
17-65-2 [handwritten at top right of form]
Full Name of Child: - Cejnar
Sex: Female
Date of this birth: January 10, 1902
Place of Birth: 915 - 31st Pl., City [circled]
Full Name of Father: Franciszek Cejnar
Reported by: Antonia Gaura, midwife [circled]
Date: January 15, 1902"