| Certificate Number | 640 | | Date Issued |
| Child Given Name | Ella |
Anderson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 May 1883 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Nelse |
Anderson | Father's Surname |
| Father's Occupation | Farmer | Dane | Father's Nationality |
| Father's Birth Place | Denmark | 38 | Father's Age |
| Mother's Given Name | Ann Sophia | Larsen | Mother's Maiden Name |
| Mother's Surname | Anderson | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Dane | Denmark | Mother's Birth Place |
| Mother's Age | 39 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Mary Larson | Warren Twp | Medical Attendant's Address |
| Certificate Signer's Name | Mary Larson | Warren Twp | Certificate Signer's Address |
| Returned by Name | Mary Larson | | |