| Certificate Number | 246 | | Date Issued |
| Child Given Name | Carl T. |
Anderson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Sep 1889 |
Slater Story Co IA | Place of Birth |
| Father's Given Name | Frank |
Anderson | Father's Surname |
| Father's Occupation | Merchant | Swede | Father's Nationality |
| Father's Birth Place | Illinois | 29 | Father's Age |
| Mother's Given Name | Emma | Deashore | Mother's Maiden Name |
| Mother's Surname | | Slater Ia | Mother's Residence |
| Mother's Nationality | Swede | Sweden | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.A. Rawson | Slater Ia | Medical Attendant's Address |