| Certificate Number | 48 | | Date Issued |
| Child Given Name | |
Ray | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 31 Dec 1887 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Jacob |
Ray | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 40 | Father's Age |
| Mother's Given Name | Lucy J. | White | Mother's Maiden Name |
| Mother's Surname | Ray | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 40 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |