| Certificate Number | 463 | | Date Issued |
| Child Given Name | |
Ray | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 06 Sep 1882 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Archibald |
Ray | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 37 | Father's Age |
| Mother's Given Name | Hilda Josephine | Johnson | Mother's Maiden Name |
| Mother's Surname | Ray | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 26 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Peter Joor M.D. | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Peter Joor M.D. | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Peter Joor M.D. | | |