| Certificate Number | 172 | | Date Issued |
| Child Given Name | Ray |
Gilbert | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Apr 1889 |
Gilbert Station Story Co IA | Place of Birth |
| Father's Given Name | E.P. |
Gilbert | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Wisconson | 32 | Father's Age |
| Mother's Given Name | Martha Mary | Dodds | Mother's Maiden Name |
| Mother's Surname | | Gilbert Station Story Co IA | Mother's Residence |
| Mother's Nationality | | Boone Co IA | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | A. Richmond | Ames IA | Medical Attendant's Address |