| Certificate Number | 764 | | Date Issued |
| Child Given Name | |
Grove | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 Jun 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Jasper |
Grove | Father's Surname |
| Father's Occupation | Clerk | | Father's Nationality |
| Father's Birth Place | | 25 | Father's Age |
| Mother's Given Name | Mrs J. | | Mother's Maiden Name |
| Mother's Surname | Grove | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |