| Certificate Number | 543 | | Date Issued |
| Child Given Name | Kittie |
Graft | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Jan 1883 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Samuel O. |
Graft | Father's Surname |
| Father's Occupation | Bridge Builder | American | Father's Nationality |
| Father's Birth Place | Ohio | 27 | Father's Age |
| Mother's Given Name | Kittie | Morgan | Mother's Maiden Name |
| Mother's Surname | Graft | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wisconson | Mother's Birth Place |
| Mother's Age | 23 | 1 | 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 | | |