| Certificate Number | 1037 | | Date Issued |
| Child Given Name | |
Kerger | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Dec 1883 |
Bloomington Story Co IA | Place of Birth |
| Father's Given Name | |
Kerger | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | | 35 | Father's Age |
| Mother's Given Name | | Lyon | Mother's Maiden Name |
| Mother's Surname | Miss | | Mother's Residence |
| Mother's Age | 30 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.A., Dr. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A., Dr. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A., Dr. Beverly | | |