| Certificate Number | 310 | | Date Issued |
| Child Given Name | |
Kittleson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Jan 1882 |
Sheldahl Story Co IA | Place of Birth |
| Father's Given Name | W.O. |
Kitleson | Father's Surname |
| Father's Occupation | Railroad Contractor | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 41 | Father's Age |
| Mother's Given Name | Fannie F. | Tomilson | Mother's Maiden Name |
| Mother's Surname | Kitleson | Sheldahl Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 35 | 5 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Anderson M.D. | | Medical Attendant's Address |
| Certificate Signer's Name | J.A. Anderson | | Certificate Signer's Address |
| Returned by Name | J.A. Anderson | | |