| Certificate Number | 167 | | Date Issued |
| Child Given Name | Floyd Earl |
Jorgenson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Frank |
Jorgenson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Monmouth IL | 25 | Father's Age |
| Mother's Given Name | Millie | Butt | Mother's Maiden Name |
| Mother's Surname | Jorgenson | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Madison WI | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | L.C., Mrs. Butt | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | L.C., Mrs. Butt | Nevada IA | Certificate Signer's Address |
| Returned by Name | L.C., Mrs. Butt | | |