| Certificate Number | 1000 | | Date Issued |
| Child Given Name | Carry M. |
Mason | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 16 Jun 1884 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Morris M. |
Mason | Father's Surname |
| Father's Occupation | Day Laborer | American | Father's Nationality |
| Father's Birth Place | Iowa | 24 | Father's Age |
| Mother's Given Name | Christina | Heggen | Mother's Maiden Name |
| Mother's Surname | Mason | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 21 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hays | Cambridge IA | Medical Attendant's Address |