| Certificate Number | 198 | | Date Issued |
| Child Given Name | |
Gridley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Jul 1890 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Norman L. |
Gridley | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Illinois | 31 | Father's Age |
| Mother's Given Name | Inez Anna | Roe | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell IA | Medical Attendant's Address |