| Certificate Number | 53 | | Date Issued |
| Child Given Name | Malinda |
Grimm | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Oct 1880 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | A.H. |
Grimm | Father's Surname |
| Father's Occupation | Farmer | German | Father's Nationality |
| Father's Birth Place | Germany | 31 | Father's Age |
| Mother's Given Name | Matilda | Stoltenberg | Mother's Maiden Name |
| Mother's Surname | Grimm | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | German | Germany | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler | Nevada IA | Certificate Signer's Address |
| Returned by Name | Lewis Schooler | | |