| Certificate Number | 875 | | Date Issued |
| Child Given Name | |
Graves | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Jan 1884 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Charles |
Graves | Father's Surname |
| Father's Occupation | Drayman | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 40 | Father's Age |
| Mother's Given Name | Mary 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 | 38 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |