| Certificate Number | 234 | | Date Issued |
| Child Given Name | |
Anderson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Aug 1881 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Robert R. |
Anderson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Clarian Co Penn | 46 | Father's Age |
| Mother's Given Name | Anna R. | Massingham | Mother's Maiden Name |
| Mother's Surname | Anderson | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wheeling WV | Mother's Birth Place |
| Mother's Age | 33 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Jno Daugherty | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno Daugherty | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno Daugherty | | |