| Certificate Number | 365 | | Date Issued |
| Child Given Name | |
Nelson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 29 Jun 1886 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Ole |
Nelson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Denmark | 45 | Father's Age |
| Mother's Given Name | Pauline | Nelson | Mother's Maiden Name |
| Mother's Surname | Nelson | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 32 | 4 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |