| Certificate Number | 302 | | Date Issued |
| Child Given Name | |
Olson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Andrew K. |
Olsen | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 32 | Father's Age |
| Mother's Given Name | Elsia | Johnson | Mother's Maiden Name |
| Mother's Surname | Olson | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 5 | Number of Child This Mother |
| Medical Attendant's Name | P., Mrs. Hopkins | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | P., Mrs. Hopkins | Cambridge IA | Certificate Signer's Address |
| Returned by Name | P., Mrs. Hopkins | | |