| Certificate Number | 96 | | Date Issued |
| Child Given Name | Claude |
Jacobson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Dec 1888 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | C.B. |
Jacobson | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Father's Birth Place | Norway | 44 | Father's Age |
| Mother's Given Name | Olsine | Olsen | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 33 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Martine Berkland | Roland IA | Medical Attendant's Address |