| Certificate Number | 109 | | Date Issued |
| Child Given Name | Ray H. |
Menzel | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Mar 1890 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank F. |
Menzel | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Minnie | Johnson | Mother's Maiden Name |
| Mother's Surname | | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |