| Certificate Number | 104 | | Date Issued |
| Child Given Name | |
Ostrem | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Dec 1883 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | H. |
Ostrem | Father's Surname |
| Father's Occupation | Clerk | | Father's Nationality |
| Father's Birth Place | Norway | 24 | Father's Age |
| Mother's Given Name | Anna | Qvalls | Mother's Maiden Name |
| Mother's Surname | Ostrem | | Mother's Residence |
| Mother's Nationality | Norwegian | Norway | Mother's Birth Place |
| Mother's Age | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |