| Certificate Number | 20 | | Date Issued |
| Child Given Name | |
Perry | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Nov 1888 |
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 | | Father's Age |
| Mother's Given Name | | Hansen | Mother's Maiden Name |
| Mother's Surname | | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |