| Certificate Number | 254 | | Date Issued |
| Child Given Name | Orville Clayton |
Ufford | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Aug 1889 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Myran C. |
Ufford | Father's Surname |
| Father's Occupation | Clerk | | Father's Nationality |
| Father's Birth Place | New York | 33 | Father's Age |
| Mother's Given Name | Ella | Chance | Mother's Maiden Name |
| Mother's Surname | | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 25 | 1 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |