| Certificate Number | 190 | | Date Issued |
| Child Given Name | Berentine |
Jondall | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Jul 1890 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Ingerbright |
Jondall | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Norway | 35 | Father's Age |
| Mother's Given Name | Berrintine | Anderson | 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 | 30 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Anna G. Takheim | Story City IA | Medical Attendant's Address |