| Child Given Name | Jane Mathilda |
Olson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 13 Apr 1884 |
Howard Twp Story Co IA | Place of Birth |
| Father's Given Name | Ole J. |
Olson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | | Father's Age |
| Mother's Given Name | Helen | Thompson | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | Norwegian | | Mother's Birth Place |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Monk | | |