| Certificate Number | 158 | | Date Issued |
| Child Given Name | Grace M. |
Hawthorn | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 02 Apr 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Isaac |
Hawthorne | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 26 | Father's Age |
| Mother's Given Name | Frances E. | Livingston | Mother's Maiden Name |
| Mother's Surname | Hawthorn | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Age | 25 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Biggess | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Biggess | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.W. Biggess | | |