| Certificate Number | 305 | | Date Issued |
| Child Given Name | Emma Ella |
Graves | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 10 Dec 1881 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Charles E. |
Graves | Father's Surname |
| Father's Occupation | Farmer | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 37 | Father's Age |
| Mother's Given Name | Mar L. | Briggs | Mother's Maiden Name |
| Mother's Surname | Graves | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 34 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Geo Frazier M.D. | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Frazier M.D. | Colo IA | Certificate Signer's Address |
| Returned by Name | Geo Frazier M.D. | | |