| Certificate Number | 333 | | Date Issued |
| Child Given Name | Margaret |
Mathenson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 May 1886 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Lars |
Mathenson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 48 | Father's Age |
| Mother's Given Name | Sina | Peterson | Mother's Maiden Name |
| Mother's Surname | Mathenson | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 38 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Henry Monk M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Henry Monk M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | Henry Monk M.D. | | |