| Certificate Number | 174 | | Date Issued |
| Child Given Name | Hazel P. |
Peterson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Jul 1890 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | John |
Peterson | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Denmark | 39 | Father's Age |
| Mother's Given Name | Serrine | Christiansen | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 27 | 5 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |