| Certificate Number | 1061 | | Date Issued |
| Child Given Name | |
Perry | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Aug 1884 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Chas. |
Perry | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Marshall Co IA | 28 | Father's Age |
| Mother's Given Name | Ellen | Miller | Mother's Maiden Name |
| Mother's Surname | Perry | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Marshall Co IA | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Blaney | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | Mrs. Blaney | Zearing IA | Certificate Signer's Address |
| Returned by Name | Chas. Perry | | |