| Certificate Number | 532 | | Date Issued |
| Child Given Name | |
Olsen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Jan 1883 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Olsen | Father's Surname |
| Father's Occupation | Section Boss | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 28 | Father's Age |
| Mother's Given Name | Martha J. | Jentian | Mother's Maiden Name |
| Mother's Surname | Olsen | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |