| Certificate Number | 200 | | Date Issued |
| Child Given Name | Earl Clifford |
Brouhard | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Apr 1889 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Barnett |
Brouhard | Father's Surname |
| Father's Occupation | Plaster | | Father's Nationality |
| Father's Birth Place | Indiana | 55 | Father's Age |
| Mother's Given Name | Sarah | Sarsfield | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 35 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |