The document went from physical to electronic to physical then to electronic.
It started out physical, bound into a book in the Hawaii DoH's records storage room. They took the book down off the shelf, opened it to Obama's page, and pressed it onto the copier glass. Then it went electronic as the copier scanned it and back to physical as the copier printed the copy (actually two copies were made, if memory serves).
Then they stamped and dated the copies with Dr Onaka's official stamp and turned them over to Obama's lawyer, who hand-carried them back to the White House.
At the White House, they scanned one or both of the copies back into electronic form and gave the PDF out to the press.
So, the question is, at what point did the forgery take place, if it took place? And with what purpose?
Remember, the original is still in the book on the shelf at the Hawaii DoH. If the electronic document the White House put out has any substantive discrepancies (facts, not pixels, that is) vs the document in the book, then the Hawaii DoH ought to be blowing the whistle! Unless they are in on it, which would be huge. But in that case no WH forgery would have been needed.
What happened with this document could only happen if someone took an image, scanned it to a computer, and then digitally altered it. It could not have been digitally altered from Hawaii, and then printed, redigitized, printed, and digitized again, because the act of printing and then taking a photocopy of the image (as they claimed they did) would have eliminated any artifact that pointed to intentional editing.