| Certificate Number | 319 | | Date Issued |
| Child Given Name | |
Peterson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 May 1886 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Carl A. |
Peterson | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | East Justland Sweden | 30 | Father's Age |
| Mother's Given Name | Augusta | Lindell | Mother's Maiden Name |
| Mother's Surname | Peterson | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | East Justland Sweden | Mother's Birth Place |
| Mother's Age | 29 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Hilda Roberg | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |