| Certificate Number | 276 | | Date Issued |
| Child Given Name | Grace Eunice |
Fuller | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Feb 1886 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | H.C. |
Fuller | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 32 | Father's Age |
| Mother's Given Name | Carrie E. | Ingram | Mother's Maiden Name |
| Mother's Surname | Fuller | | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |