| Certificate Number | 156 | | Date Issued |
| Child Given Name | Alice F. |
Peterson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 13 May 1890 |
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 | 38 | Father's Age |
| Mother's Given Name | Anna H. | Henderson | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 33 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Jane L. Bartlett | Ames IA | Medical Attendant's Address |