| Certificate Number | 96 | | Date Issued |
| Child Given Name | Emmie |
Anderson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Dec 1880 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Anderson | Father's Surname |
| Father's Occupation | Farmer | Danish | Father's Nationality |
| Father's Birth Place | Denmark | 38 | Father's Age |
| Mother's Given Name | Celia | Johnson | Mother's Maiden Name |
| Mother's Surname | Anderson | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Leo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Leo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Leo Stitzell | | |