| Certificate Number | 1027 | | Date Issued |
| Child Given Name | Clella Ray |
Spohn | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 23 Jul 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | M.J. |
Spohn | Father's Surname |
| Father's Occupation | Mason | American | Father's Nationality |
| Father's Birth Place | Iowa | 32 | Father's Age |
| Mother's Given Name | Belle | Morris | Mother's Maiden Name |
| Mother's Surname | Spohn | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 30 | | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |