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 | | |