| Certificate Number | 87 | | Date Issued |
| Child Given Name | John J. |
Burkhart | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Nov 1889 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | John |
Burkhart | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Germany | 45 | Father's Age |
| Mother's Given Name | Lena | Bernicker | 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 | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |