| Certificate Number | 7 | | Date Issued |
| Child Given Name | |
Peterson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Aug 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Peterson | Father's Surname |
| Father's Occupation | Ditcher | | Father's Nationality |
| Father's Birth Place | Denmark | 35 | Father's Age |
| Mother's Given Name | Anna | Hendricks | Mother's Maiden Name |
| Mother's Surname | Peterson | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 29 | 5 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |