| Certificate Number | 768 | | Date Issued |
| Child Given Name | Ross E. |
Fry | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Sep 1883 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Fry | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 26 | Father's Age |
| Mother's Given Name | Ida May | Kelly | Mother's Maiden Name |
| Mother's Surname | Fry | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J. Daugherty | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J. Daugherty | Colo IA | Certificate Signer's Address |
| Returned by Name | J. Daugherty | | |