| Certificate Number | 465 | | Date Issued |
| Child Given Name | Miss |
Perry | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Sep 1882 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | Charles H. |
Perry | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 26 | Father's Age |
| Mother's Given Name | Ella J. | Miller | Mother's Maiden Name |
| Mother's Surname | Perry | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton M.D. | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton M.D. | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton M.D. | | |