| Certificate Number | 109 | | Date Issued |
| Child Given Name | Amanda M. |
Nernes | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Mar 1888 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Nerness | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 33 | Father's Age |
| Mother's Given Name | Margarett | Thompson | Mother's Maiden Name |
| Mother's Surname | | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 21 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Margaret Nerness | Cambridge IA | Medical Attendant's Address |