| Certificate Number | 183 | | Date Issued |
| Child Given Name | |
Ostrem | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 May 1889 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | John |
Ostrem | Father's Surname |
| Father's Birth Place | Norway | 48 | Father's Age |
| Mother's Given Name | Ragnell | Sivenson | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 43 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Martine Birkland | Roland IA | Medical Attendant's Address |