| Certificate Number | 222 | | Date Issued |
| Child Given Name | |
Berry | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Jul 1889 |
Kelly Story Co IA | Place of Birth |
| Father's Given Name | Jas. A. |
Berry | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 33 | Father's Age |
| Mother's Given Name | Margaret | Corrall | Mother's Maiden Name |
| Mother's Surname | | Kelly 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 | B.D. Miller | Kelley IA | Medical Attendant's Address |