| Certificate Number | 651 | | Date Issued |
| Child Given Name | |
Briley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Jun 1883 |
| Place of Birth |
| Father's Given Name | Elisha |
Briley | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 49 | Father's Age |
| Mother's Given Name | Mary E. | Tofer | Mother's Maiden Name |
| Mother's Surname | Briley | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 13 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merridith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merridith | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Merridith | | |