| Certificate Number | 61 | | Date Issued |
| Child Given Name | Leta B. |
Raymond | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Dec 1889 |
Gilbert Story Co IA | Place of Birth |
| Father's Given Name | E.E. |
Raymond | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Dora B. | Willoughby | Mother's Maiden Name |
| Mother's Surname | | Gilbert Station Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.J., Mrs. Willoughby | Indianola IA | Medical Attendant's Address |