| Certificate Number | 152 | | Date Issued |
| Child Given Name | Grace Martin |
F | Child Surname |
| Child Sex | 3 |
| Child Race |
| Date of Birth | 13 Apr 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Levi Henry |
Martin | Father's Surname |
| Father's Occupation | Operator | American | Father's Nationality |
| Father's Birth Place | Cleveland OH | 26 | Father's Age |
| Mother's Given Name | Alfeda Jane | Talbout | Mother's Maiden Name |
| Mother's Surname | Martin | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Monmouth IL | Mother's Birth Place |
| Mother's Age | 26 | | Number of Child This Mother |
| Medical Attendant's Name | S. Butt | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | S. Butt | Nevada IA | Certificate Signer's Address |
| Returned by Name | S. Butt | | |