| Certificate Number | 237 | | Date Issued |
| Child Given Name | Henry O. |
Schaudt | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Aug 1890 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | G. |
Schaudt | Father's Surname |
| Father's Occupation | Mechanic | | Father's Nationality |
| Father's Birth Place | Germany | 34 | Father's Age |
| Mother's Given Name | Mary | Bauer | 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 | 32 | 7 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |