| Certificate Number | 84 | | Date Issued |
| Child Given Name | Peter |
Hansen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Jan 1888 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Hansen | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Norway | 32 | Father's Age |
| Mother's Given Name | Welhelmine | Eversen | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 29 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Mary, Mrs. Johnsen | Nevada IA | Medical Attendant's Address |