| Certificate Number | 550 | | Date Issued |
| Child Given Name | Andrew Melvin |
Picht | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Mar 1887 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Picht | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Germany | 30 | Father's Age |
| Mother's Given Name | Clara M. | | Mother's Maiden Name |
| Mother's Surname | Picht | | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |