| Certificate Number | 819 | | Date Issued |
| Child Given Name | Ameka |
Anderson | Child Surname |
| Child Sex | |
W | Child Race |
| Date of Birth | 27 Oct 1883 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Hans Peter |
Anderson | Father's Surname |
| Father's Occupation | Section Hand | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 21 | Father's Age |
| Mother's Given Name | Maria | | Mother's Maiden Name |
| Mother's Surname | Anderson | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 18 | | 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 | | |