| Certificate Number | 801 | | Date Issued |
| Child Given Name | Lillian Madge |
Peters | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Nov 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | George N. |
Peters | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Coxhocton Co OH | 36 | Father's Age |
| Mother's Given Name | Angelina M. | Hadley | Mother's Maiden Name |
| Mother's Surname | Peterson | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | New Hampshire | Mother's Birth Place |
| Mother's Age | 29 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Masters | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Mrs. Masters | Nevada IA | Certificate Signer's Address |
| Returned by Name | Mrs. Butt | | |