| Certificate Number | 218 | | Date Issued |
| Child Given Name | |
Henriksen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Jul 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Martin |
Henriksen | Father's Surname |
| Father's Occupation | Blacksmith | | Father's Nationality |
| Father's Birth Place | Denmark | 25 | Father's Age |
| Mother's Given Name | May | Johnson | Mother's Maiden Name |
| Mother's Surname | Henricksen | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 22 | 1 | 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 | | |