| Certificate Number | 542 | | Date Issued |
| Child Given Name | Chume Iranie |
Anderson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Dec 1882 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Emery E. |
Anderson | Father's Surname |
| Father's Occupation | Clerk | American | Father's Nationality |
| Father's Birth Place | Illinois | 20 | Father's Age |
| Mother's Given Name | Harriet F. | Moore | Mother's Maiden Name |
| Mother's Surname | Anderson | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 27 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |