| Certificate Number | 226 | | Date Issued |
| Child Given Name | J.I. |
Hendricksen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Sep 1890 |
McCallsburg Story Co IA | Place of Birth |
| Father's Given Name | C.H. |
Hendricksen | Father's Surname |
| Father's Occupation | Grain Buyer | | Father's Nationality |
| Father's Birth Place | Indiana | 28 | Father's Age |
| Mother's Given Name | Astigal | Griffith | Mother's Maiden Name |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |