| Child Given Name | J. Clarence |
Fry | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Oct 1886 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | John Valentine |
Fry | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 31 | Father's Age |
| Mother's Given Name | Ida May | Kelley | Mother's Maiden Name |
| Mother's Surname | | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Mead | John V. | Medical Attendant's Address |
| Certificate Signer's Name | Fry | | Certificate Signer's Address |