| Certificate Number | 103 | | Date Issued |
| Child Given Name | Chara G. |
Grimm | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Feb 1890 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | A.H. |
Grimm | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Germany | 39 | Father's Age |
| Mother's Given Name | Matilda | Stoltanberg | Mother's Maiden Name |
| Mother's Surname | | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | In the ocean near Scotland | Mother's Birth Place |
| Mother's Age | 34 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Jeffry | Nevada IA | Medical Attendant's Address |