| Certificate Number | 93 | | Date Issued |
| Child Given Name | |
Olsen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Dec 1888 |
Howard Twp Story Co IA | Place of Birth |
| Father's Given Name | Hans |
Olson | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Norway | 35 | Father's Age |
| Mother's Given Name | Siri | Dale | Mother's Maiden Name |
| Mother's Surname | | Howard Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 32 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Martine Birkeland | Roland IA | Medical Attendant's Address |