| Certificate Number | 247 | | Date Issued |
| Child Given Name | |
Jacobson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Sep 1881 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | G.C. |
Jacobson | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 36 | Father's Age |
| Mother's Given Name | Josephine | Oleson | Mother's Maiden Name |
| Mother's Surname | Jacobson | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 26 | 5 | Number of Child This Mother |
| Medical Attendant's Name | G.H. Meredith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.H. Meredith | Ames IA | Certificate Signer's Address |
| Returned by Name | G.H. Meredith | | |