| Certificate Number | 529 | | Date Issued |
| Child Given Name | Carrie |
Peterson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Dec 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | John |
Peterson | Father's Surname |
| Father's Occupation | Laborer | Dane | Father's Nationality |
| Father's Birth Place | Denmark | 32 | Father's Age |
| Mother's Given Name | Lene | Christian | Mother's Maiden Name |
| Mother's Surname | Peterson | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |