| Certificate Number | 111 | | Date Issued |
| Child Given Name | Thrine |
Holter | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Mar 1890 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Christian |
Holter | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Father's Birth Place | Norway | 35 | Father's Age |
| Mother's Given Name | Anna | Anderson | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 33 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Gretha M. Skogerboe | Roland IA | Medical Attendant's Address |