| Certificate Number | 185 | | Date Issued |
| Child Given Name | |
Larson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Jul 1890 |
Howard Twp Story Co IA | Place of Birth |
| Father's Given Name | S. Lewis |
Larson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 27 | Father's Age |
| Mother's Given Name | Ella | Erickson | Mother's Maiden Name |
| Mother's Surname | | Howard Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |