| Certificate Number | 412 | | Date Issued |
| Child Given Name | |
Rod | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Sep 1882 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Erick M. |
Rod | Father's Surname |
| Father's Occupation | Clerk | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 22 | Father's Age |
| Mother's Given Name | Julia C. | Rod | Mother's Maiden Name |
| Mother's Surname | Jacobson | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar M.D. | | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar M.D. | | Certificate Signer's Address |
| Returned by Name | P.W. Farrar M.D. | | |