| Certificate Number | 172 | | Date Issued |
| Child Given Name | Emma |
Berger | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | |
Colo Story Co IA | Place of Birth |
| Father's Given Name | John |
Berger | Father's Surname |
| Father's Occupation | Laborer | German | Father's Nationality |
| Father's Birth Place | Germany | 38 | Father's Age |
| Mother's Given Name | Kemegunda | Hartman | Mother's Maiden Name |
| Mother's Surname | Berger | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | German | Germany | Mother's Birth Place |
| Mother's Age | 40 | 7 | Number of Child This Mother |
| Medical Attendant's Name | John I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | John I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | John I. Hostetter | | |