| Certificate Number | 190 | | Date Issued |
| Child Given Name | |
Picht | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Philip |
Picht | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Germany | 27 | Father's Age |
| Mother's Given Name | E.J. | French | Mother's Maiden Name |
| Mother's Surname | | Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Abby M. Penn | Nevada IA | Medical Attendant's Address |