| Certificate Number | 437 | | Date Issued |
| Child Given Name | Lynn |
Jorenson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Nov 1886 |
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 | Wisconson | 26 | 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 | | Illinois | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Monk | | |