| Certificate Number | 479 | | Date Issued |
| Child Given Name | Grace Maude |
Bunce | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Jul 1882 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | David King |
Bunce | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 37 | Father's Age |
| Mother's Given Name | Elizabeth | Linnode | Mother's Maiden Name |
| Mother's Surname | Bunce | | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 34 | 5 | Number of Child This Mother |
| Medical Attendant's Name | James Bradley | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | James Bradley | Ames IA | Certificate Signer's Address |
| Returned by Name | James Bradley | | |