| Certificate Number | 11 | | Date Issued |
| Child Given Name | Marion Elian |
Olson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Nov 1888 |
Slater Story Co IA | Place of Birth |
| Father's Given Name | Brit B. |
Olson | Father's Surname |
| Father's Occupation | R.R. Employee | | Father's Nationality |
| Father's Birth Place | Norway | 29 | Father's Age |
| Mother's Given Name | Julia | Ferguson | Mother's Maiden Name |
| Mother's Surname | | Slater Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.A. Rawson M.D. | Slater IA | Medical Attendant's Address |
| Certificate Signer's Name | Margaret Rudolph | Bellvue WA | Certificate Signer's Address |