| Certificate Number | 604 | | Date Issued |
| Child Given Name | Grace Ellen |
Mackey | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Apr 1883 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | David N. |
Mackey | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 37 | Father's Age |
| Mother's Given Name | Sarah | Smay | Mother's Maiden Name |
| Mother's Surname | Mackey | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 36 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler | Nevada IA | Certificate Signer's Address |
| Returned by Name | Lewis Schooler | | |