| Certificate Number | 79 | | Date Issued |
| Child Given Name | |
Olson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Dec 1888 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Carl |
Olson | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Iowa | 27 | Father's Age |
| Mother's Given Name | Anna | Swenson | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Martine Birkeland | Roland IA | Medical Attendant's Address |