| Certificate Number | 835 | | Date Issued |
| Child Given Name | |
Anderson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Dec 1883 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Carl |
Anderson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Story Co IA | 22 | Father's Age |
| Mother's Given Name | Susan | Rech | Mother's Maiden Name |
| Mother's Surname | Anderson | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Story Co IA | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo. Stitzell | | |