| Certificate Number | 139 | | Date Issued |
| Child Given Name | |
Larson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Nov 1884 |
Story Co IA | Place of Birth |
| Father's Given Name | Jens |
Larson | Father's Surname |
| Father's Occupation | Blacksmith | Dane | Father's Nationality |
| Father's Birth Place | Denmark | 37 | Father's Age |
| Mother's Given Name | Marie | Jensen | Mother's Maiden Name |
| Mother's Surname | Larson | Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | 36 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Abbie M. Person | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Abbie M. Person | Nevada IA | Certificate Signer's Address |
| Returned by Name | Abbie M. Person | | |