| Certificate Number | 176 | | Date Issued |
| Child Given Name | Bertha |
Olson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Jun 1888 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Peder |
Olson | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Norway | 55 | Father's Age |
| Mother's Given Name | Arlette | Olson | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 36 | 10 | Number of Child This Mother |
| Medical Attendant's Name | John Emmet | Story City IA | Medical Attendant's Address |