| Certificate Number | 213 | | Date Issued |
| Child Given Name | Lulu |
Christofferson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Jul 1880 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Christofferson | Father's Surname |
| Father's Occupation | Farmer | Dane | Father's Nationality |
| Father's Birth Place | Denmark | | Father's Age |
| Mother's Given Name | Minna | Nelson | Mother's Maiden Name |
| Mother's Surname | Christofferson | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |