| Certificate Number | 381 | | Date Issued |
| Child Given Name | |
Hendrickson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Jul 1886 |
Hamilton Co IA | Place of Birth |
| Father's Given Name | Ben |
Hendrickson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 36 | Father's Age |
| Mother's Given Name | Anna | Bomenson | Mother's Maiden Name |
| Mother's Surname | Hendrickson | | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 31 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |