| Certificate Number | 41 | | Date Issued |
| Child Given Name | Julia A. |
Holm | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Oct 1888 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | T.T. |
Holen | Father's Surname |
| Father's Occupation | Harness Maker | | Father's Nationality |
| Father's Birth Place | Norway | 31 | Father's Age |
| Mother's Given Name | Maria | Christenson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | John Emmett | Story City IA | Medical Attendant's Address |