| Certificate Number | 369 | | Date Issued |
| Child Given Name | Maud |
Gray | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Aug 1886 |
| Place of Birth |
| Father's Given Name | James H. |
Gray | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 30 | Father's Age |
| Mother's Given Name | Mable | Gaige | Mother's Maiden Name |
| Mother's Surname | Gray | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |