| Certificate Number | 127 | | Date Issued |
| Child Given Name | Anna |
Nelson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Apr 1890 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Nels P. |
Nelson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | | 34 | Father's Age |
| Mother's Given Name | Ellen | Jensen | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | America | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Grethe M. Skogerboe | Roland IA | Medical Attendant's Address |