| Certificate Number | 240 | | Date Issued |
| Child Given Name | Jacob |
Jacobson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 06 Jan 1889 |
| Place of Birth |
| Father's Given Name | Jacob |
Jacobson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 33 | Father's Age |
| Mother's Given Name | | Johnson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |