| Certificate Number | 275 | | Date Issued |
| Child Given Name | Jay Wesley |
Granger | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 30 Oct 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | P.E. |
Granger | Father's Surname |
| Father's Occupation | Grain Business | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 57 | Father's Age |
| Mother's Given Name | Eliza | Graves | Mother's Maiden Name |
| Mother's Surname | Granger | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Vermont | Mother's Birth Place |
| Mother's Age | 50 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |