| Certificate Number | 27 | | Date Issued |
| Child Given Name | Wm. H. |
Shoudt | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Oct 1888 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Gothold |
Shoudt | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Germany | 40 | Father's Age |
| Mother's Given Name | Mary | Baur | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Germany | Mother's Birth Place |
| Mother's Age | 35 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Mary Morgan | Colo IA | Medical Attendant's Address |