| Certificate Number | 241 | | Date Issued |
| Child Given Name | Ray |
Parriot | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Aug 1881 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Wesley |
Pariott | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 34 | Father's Age |
| Mother's Given Name | Mary | Posegate | Mother's Maiden Name |
| Mother's Surname | Pariott | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Union Twp Story Co IA | Mother's Birth Place |
| Mother's Age | 26 | 5 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |