| Certificate Number | 228 | | Date Issued |
| Child Given Name | |
Christopherson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Christopherson | Father's Surname |
| Father's Occupation | Farmer | Dane | Father's Nationality |
| Father's Birth Place | Denmark | 24 | Father's Age |
| Mother's Given Name | Minnie | Nelson | Mother's Maiden Name |
| Mother's Surname | Christopherson | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | 24 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Geo. A. Meridith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. A. Meridith | Ames IA | Certificate Signer's Address |
| Returned by Name | Geo. A. Meridith | | |