| Certificate Number | 210 | | Date Issued |
| Child Given Name | |
Hovlan | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Aug 1890 |
McCallsburg Story Co IA | Place of Birth |
| Father's Given Name | Anarra J. |
Hovlan | Father's Surname |
| Father's Occupation | Section Boss | | Father's Nationality |
| Father's Birth Place | Norway | 42 | Father's Age |
| Mother's Given Name | Astrua | Jacobson | Mother's Maiden Name |
| Mother's Surname | | McCallsburg Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 36 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |