| Certificate Number | 657 | | Date Issued |
| Child Given Name | |
Peterson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo |
Peterson | Father's Surname |
| Father's Occupation | Farmer | Dane | Father's Nationality |
| Father's Birth Place | Denmark | 41 | Father's Age |
| Mother's Given Name | Mary | Madson | Mother's Maiden Name |
| Mother's Surname | Peterson | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | 43 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |