| Certificate Number | 217 | | Date Issued |
| Child Given Name | Charles P. |
Raff | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Jan 1882 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | France |
Raff | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | | Father's Age |
| Mother's Given Name | Mary | Eastwood | Mother's Maiden Name |
| Mother's Surname | | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.F. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.F. Fairchild | | |