| Certificate Number | 289 | | Date Issued |
| Child Given Name | |
Anderson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Aug 1889 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Carl |
Anderson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 27 | Father's Age |
| Mother's Given Name | Susan | Rich | Mother's Maiden Name |
| Mother's Surname | | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |