| Certificate Number | 86 | | Date Issued |
| Child Given Name | Mary |
Grafton | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Feb 1885 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Wm H. |
Grafton | Father's Surname |
| Father's Occupation | Physician | American | Father's Nationality |
| Father's Birth Place | Baltimore MD | 57 | Father's Age |
| Mother's Given Name | Sarah B. | Livingston | Mother's Maiden Name |
| Mother's Surname | Grafton | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 34 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Wm H. Grafton | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | Wm H. Grafton | Cambridge IA | Certificate Signer's Address |
| Returned by Name | Wm H. Grafton | | |