| Certificate Number | 414 | | Date Issued |
| Child Given Name | |
Roe | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Aug 1882 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Ole O. |
Roe | Father's Surname |
| Father's Occupation | Attorney | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 28 | Father's Age |
| Mother's Given Name | Sarah | Olsen | Mother's Maiden Name |
| Mother's Surname | Roe | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar M.D. | | |