| Certificate Number | 194 | | Date Issued |
| Child Given Name | Peter |
Jensen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 May 1889 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Jensen | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Denmark | 39 | Father's Age |
| Mother's Given Name | Inge May | Nelson | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 33 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Mary, Mrs. Johnson | Nevada IA | Medical Attendant's Address |