| Certificate Number | 716 | | Date Issued |
| Child Given Name | Russell D. |
Perry | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Jul 1883 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Erastus |
Perry | Father's Surname |
| Father's Occupation | Blacksmith | American | Father's Nationality |
| Father's Birth Place | Wisconson | 29 | Father's Age |
| Mother's Given Name | Caroline | Tight | Mother's Maiden Name |
| Mother's Surname | Perry | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 1 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Brooks | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Brooks | | |