| Certificate Number | 612 | | Date Issued |
| Child Given Name | |
Anderson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Aug 1887 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Fredrick |
Anderson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 46 | Father's Age |
| Mother's Given Name | Marie | Osterson | Mother's Maiden Name |
| Mother's Surname | Anderson | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 37 | 4 | Number of Child This Mother |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |