| Certificate Number | 697 | | Date Issued |
| Child Given Name | |
Pulmer | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Feb 1883 |
Shedahl Story Co IA | Place of Birth |
| Father's Given Name | John |
Pulmer | Father's Surname |
| Father's Occupation | Laborer | Swede | Father's Nationality |
| Father's Birth Place | Sweden | 25 | Father's Age |
| Mother's Given Name | Matilda Sophia | Colswin | Mother's Maiden Name |
| Mother's Surname | Pulmer | Sheldahl Story Co IA | Mother's Residence |
| Mother's Nationality | Swede | Sweden | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo A. Anderson | Sheldahl IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo A. Anderson | Sheldahl IA | Certificate Signer's Address |
| Returned by Name | Geo A. Anderson | | |