| Certificate Number | 540 | | Date Issued |
| Child Given Name | Mabel Lena |
Ray | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Mar 1887 |
| Place of Birth |
| Father's Given Name | John |
Ray | Father's Surname |
| Father's Birth Place | Indiana | 36 | Father's Age |
| Mother's Given Name | Mary K. | McCord | Mother's Maiden Name |
| Mother's Surname | Ray | | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 34 | 6 | Number of Child This Mother |
| Certificate Signer's Name | | Maxwell IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |