| Certificate Number | 18 | | Date Issued |
| Child Given Name | Syliva M. |
Larson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Oct 1884 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Jonas T. |
Larson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 52 | Father's Age |
| Mother's Given Name | Carrie | Otteson | Mother's Maiden Name |
| Mother's Surname | Larson | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 30 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |