| Certificate Number | 536 | | Date Issued |
| Child Given Name | |
Holen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Mar 1887 |
| Place of Birth |
| Father's Given Name | Thomas |
Holen | Father's Surname |
| Father's Occupation | Harness Maker | | Father's Nationality |
| Father's Birth Place | Norway | 30 | Father's Age |
| Mother's Given Name | Mary | Christianson | Mother's Maiden Name |
| Mother's Surname | Holm | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |