| Certificate Number | 180 | | Date Issued |
| Child Given Name | Elmer Lee |
Picht | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Jun 1890 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Albert |
Picht | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Germany | 25 | Father's Age |
| Mother's Given Name | | Johnson | Mother's Maiden Name |
| Mother's Surname | | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Virginia | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |