| Certificate Number | 39 | | Date Issued |
| Child Given Name | Anna Maria Hansena |
Jensen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Oct 1889 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Fred |
Jensen | Father's Surname |
| Father's Occupation | Clerk | | Father's Nationality |
| Father's Birth Place | Denmark | 25 | Father's Age |
| Mother's Given Name | Ellen | Johnson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Peterson | Story City IA | Medical Attendant's Address |