| Certificate Number | 830 | | Date Issued |
| Child Given Name | Teddy Ray |
Ferrel | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Nov 1883 |
McCallsburg Story Co IA | Place of Birth |
| Father's Given Name | Henry Clary |
Ferrel | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Williamstown Wood Co WI | 22 | Father's Age |
| Mother's Given Name | Eunica M. | Bagley | Mother's Maiden Name |
| Mother's Surname | Ferrel | McCallsburg Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 21 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Susannah C. Jersey | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | Susannah C. Jersey | Zearing IA | Certificate Signer's Address |
| Returned by Name | Susannah C. Jersey | | |