| Certificate Number | 300 | | Date Issued |
| Child Given Name | |
Matison | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Sep 1889 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Larsen |
Matisen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 51 | Father's Age |
| Mother's Given Name | Sina | Peterson | Mother's Maiden Name |
| Mother's Surname | | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 41 | 10 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |