| Certificate Number | 137 | | Date Issued |
| Child Given Name | M. Larson |
Nelsine | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Apr 1890 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Lewis A. |
Larson | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Sarah | Fatland | Mother's Maiden Name |
| Mother's Surname | | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |