| Certificate Number | 143 | | Date Issued |
| Child Given Name | Hazel Johanna |
Peterson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 May 1890 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | M.L. |
Peterson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Wisconson | 33 | Father's Age |
| Mother's Given Name | Nettie E. | Miller | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 30 | 7 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlain | Nevada IA | Medical Attendant's Address |