| Certificate Number | 19 | | Date Issued |
| Child Given Name | Hanna Petra |
Jacobson | Child Surname |
| Child Sex | Female |
A | Child Race |
| Date of Birth | 05 Jul 1880 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | C.B., Rev. |
Jacobson | Father's Surname |
| Father's Occupation | Minister of the Gospel | Norwegian | Father's Nationality |
| Father's Birth Place | Bergen Norway | 39 | Father's Age |
| Mother's Given Name | Petra Olsene | Olsen | Mother's Maiden Name |
| Mother's Surname | Jacobson | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Bergen Norway | Mother's Birth Place |
| Mother's Age | 25 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Berthe Hegland | Roland IA | Medical Attendant's Address |
| Returned by Name | C.B., Rev. Jacobson | | |