| Certificate Number | 100 | | Date Issued |
| Child Given Name | |
Norem | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Feb 1889 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Mikel |
Norem | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 26 | Father's Age |
| Mother's Given Name | Belle | Olsen | Mother's Maiden Name |
| Mother's Surname | | Sheldahl Story Co IA | Mother's Residence |
| Mother's Nationality | | Sheldahl IA | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Martine Birkeland | Roland IA | Medical Attendant's Address |