| Certificate Number | 119 | | Date Issued |
| Child Given Name | Julia N. |
Nordskog | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Mar 1890 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Sivert |
Nordskog | Father's Surname |
| Father's Occupation | Butcher | | Father's Nationality |
| Father's Birth Place | Norway | 30 | Father's Age |
| Mother's Given Name | Bertha | Johnson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 30 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Sina Peterson | Story City IA | Medical Attendant's Address |