| Certificate Number | 1060 | | Date Issued |
| Child Given Name | Margaret |
Peterson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 Jul 1884 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | John |
Peterson | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Denmark | 28 | Father's Age |
| Mother's Given Name | Sena | Paulson | Mother's Maiden Name |
| Mother's Surname | Petersen | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |