| Certificate Number | 304 | | Date Issued |
| Child Given Name | Henrietta |
Shaudt | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Apr 1885 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Gotthold |
Shaudt | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Germany | 30 | Father's Age |
| Mother's Given Name | Mary | Baaer | Mother's Maiden Name |
| Mother's Surname | Shaudt | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Germany | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |