| Certificate Number | 501 | | Date Issued |
| Child Given Name | William Clifton |
Brouhard | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Mar 1887 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Barnett |
Brouhard | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Indiana | 53 | Father's Age |
| Mother's Given Name | Sarah J. | Sarsfield | Mother's Maiden Name |
| Mother's Surname | Brouhard | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 33 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |