| Certificate Number | 255 | | Date Issued |
| Child Given Name | Benjamin Martin |
Overland | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Aug 1889 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Halvor J. |
Overland | Father's Surname |
| Father's Occupation | Blacksmith | | Father's Nationality |
| Father's Birth Place | Norway | 35 | Father's Age |
| Mother's Given Name | Dena | Barns | 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 | 28 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Anna G. Torkham | Story City IA | Medical Attendant's Address |