| Certificate Number | 322 | | Date Issued |
| Child Given Name | May |
Peterson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 13 Jun 1886 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | John |
Peterson | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Denmark | 36 | Father's Age |
| Mother's Given Name | Lena | Christensen | Mother's Maiden Name |
| Mother's Surname | Peterson | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.D. Fulhaim M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.D. Fulhaim M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.D. Fulhaim M.D. | | |