| Certificate Number | 467 | | Date Issued |
| Child Given Name | Maude Gracina |
Hemstreet | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Dec 1886 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Albert N. |
Hemstreet | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 30 | Father's Age |
| Mother's Given Name | Delia S. | Thayer | Mother's Maiden Name |
| Mother's Surname | Hemstreet | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 24 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Jeffrey | Nevada IA | Medical Attendant's Address |