| Certificate Number | 44 | | Date Issued |
| Child Given Name | Ray |
Perry | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Nov 1884 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank |
Perry | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Eliza | Hauser | Mother's Maiden Name |
| Mother's Surname | Perry | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Jno. I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno. I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno. I. Hostetter | | |