| Certificate Number | 226 | | Date Issued |
| Child Given Name | Grace |
Fair | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Sep 1888 |
Story County IA | Place of Birth |
| Father's Given Name | John W. |
Fair | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 42 | Father's Age |
| Mother's Given Name | Emma | Dodge | Mother's Maiden Name |
| Mother's Surname | | Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 37 | 5 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |