| Certificate Number | 196 | | Date Issued |
| Child Given Name | Raymond Belmond |
Clift | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Oct 1885 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | N.R. |
Clift | Father's Surname |
| Father's Occupation | Grain Merchant | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 36 | Father's Age |
| Mother's Given Name | Fidelia | Edgett | Mother's Maiden Name |
| Mother's Surname | Clift | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 30 | 5 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Brooks | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Brooks | | |